Mechanisms of Mindfulness in Patients With Migraine

Results of a Qualitative Study

Paige M. Estave PhD; Caitlyn Margol BS; Summerlyn Beeghly BS; Reid Anderson BS; Mariam Shakir MS; Alexandra Coffield BS; Julia Byrnes BS; Nathaniel O'Connell PhD; Elizabeth Seng PhD; Paula Gardiner MD, MPH; Rebecca Erwin Wells MD, MPH, FAHS

Disclosures

Headache. 2023;63(3):390-409.

Abstract and Introduction

Abstract

Objective: To understand the mechanisms of mindfulness' impact on migraine.

Background: Promising mindfulness research demonstrates potential benefit in migraine, but no data-driven model exists from the lived experiences of patients that explains the mechanisms of mindfulness in migraine.

Methods: Semi-structured qualitative interviews were conducted with adults with migraine who participated in two mindfulness-based stress reduction (MBSR) clinical trials (n = 43). Interviews were audio-recorded, transcribed, and summarized into a framework matrix with development of a master codebook. Constructivist grounded theory approach was used to identify themes/subthemes.

Results: Participants who learned mindfulness techniques through MBSR experienced altered pain perception, altered response to migraine attacks and disease, increased awareness of external and internal experiences, improved overall well-being, and group benefits. Mindfulness resulted in earlier stress-body awareness and increased interoceptive awareness resulting in earlier attack recognition, leading to earlier and more effective management. Interictal factors of self-blame, guilt, and stigma decreased while migraine acceptance, hope, empowerment, self-efficacy, and self-compassion increased. Improved emotion regulation resulted in decreased fear of migraine, pain catastrophizing, anticipatory anxiety, and pain reactivity. Although taught as prevention, mindfulness was used both acutely and prophylactically. We created a conceptual model hypothesizing that MBSR skills led to an infusion of mindfulness in daily life, resulting in altered pain perception and experience, ultimately leading to improvement in overall well-being, which may positively feed back to the infusion of mindfulness in daily life. The therapeutic benefit of learning mindfulness in a group setting may moderate these effects.

Conclusions: This study identified several new potential mechanisms of mindfulness' effect on migraine. After learning MBSR skills, participants reported altered pain and migraine perception and experiences. Increased stress-body and interoceptive awareness resulted in earlier migraine awareness and treatment. Mindfulness may target important interictal factors that affect disease burden such as fear of migraine, pain catastrophizing, and anticipatory anxiety. This is the first data-driven study to help elucidate the mechanisms of mindfulness on migraine from patient voices and can help direct future research endeavors.

Introduction

Mindfulness has emerged as a potential treatment option for migraine.^[1,2] Pharmacological treatments are often limited by side effects, lack of efficacy, and/or costs.^[3–5] Prior studies have demonstrated benefits of mindfulness for chronic pain conditions.^[6] Research assessing mindfulness specifically for migraine is critical as migraine is different from chronic pain, involving intermittent unpredictable attacks of acute pain and sensory amplification (e.g., photophobia, phonophobia, osmophobia, etc.). Recent clinical trials of mindfulness interventions in patients with migraine are promising.^[2,7,8]

We conducted two randomized clinical trials evaluating Mindfulness-Based Stress Reduction (MBSR) in adults with migraine.^[9,10] MBSR was taught with the standardized curriculum of eight weekly 2-h sessions plus a "retreat" day. During the intervention, certified MBSR instructors led participants through experiential mindfulness practices including body scan, sitting meditation, walking meditation, and sitting and standing gentle mindful yoga. During these practices, participants engaged in both focused attention (sustaining attention on sensations of the breath, while disengaging from distractors such as mind-wandering) and open monitoring (nonreactive awareness of the flow of cognition, emotions, and sensations).^[11] Dialogue and inquiry provided an opportunity for participants to discuss their experiences with mindfulness practices and how to incorporate them into daily life. Typical mindfulness skills learned included use of the breath as an anchor; noticing automatic "pilot-mode" and stress reactivity; attention to body sensations; nonreactive awareness of thoughts, emotions, and sensations; awareness of pleasant, unpleasant, and neutral sensations; and nonjudgment and equanimity. For these studies, MBSR was not modified for the migraine patient population. Participants were given MP3 files or compact discs and instructed to use them for daily practice at home, with logs demonstrating average participant practice of 34 (standard deviation [SD] = 11) minutes per day in the pilot study^[9] and 33 (15) min per day in the larger study, with an average practice of 4.2 (2.5) days per week.^[10]

The neurobiological mechanisms of mindfulness are actively being explored by researchers across the world.^[12,13] We previously published a narrative review discussing potential mechanisms of mindfulness in migraine, which included the following: (1) alterations in pain perception via decoupling the sensory and affective components of pain; (2) enhanced interoceptive body awareness; (3) regulation of autonomic dysfunction seen in patients with migraine; and (4) improved cognitive modulation of pain.^[2] Quantitative results from our clinical trials showed meaningful clinical improvements in headache-related disability, pain catastrophizing, headache self-efficacy, and depressive symptoms, with benefits seen out to 36 weeks.^[9,10] After MBSR, participants had a 36% reduction in response to experimental heat pain intensity and a 30% reduction in heat pain unpleasantness, suggesting a shift in pain perception that may alter migraine experience.^[10] To further understand these quantitative findings and to investigate the mechanisms of how mindfulness impacts migraine, we went to the lived experiences of the participants with migraine who took the MBSR course. To ensure that we fully captured their experiences, and since there is currently no data-driven model that explains the mechanisms of mindfulness in migraine, we used a hypothesis-free, constructivist grounded theory approach to analyze the qualitative interviews.^[9,10] The objective of our study was to better understand potential mechanisms of mindfulness' benefit on migraine by listening to and understanding the patient perspective.

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Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Baseline characteristics of study participants from both clinical trials.
Baseline characteristic	Pilot RCT with MBSR n = 10 n (%)	Larger RCT with MBSR n = 37^a n (%)	Combined pilot and larger RCTs (n = 47) N (%)
Sociodemographics
Age (years); mean (SD)	46 (17)	44 (12)	44.43 (13)
Sex
Female	9 (90)	34 (92)	43 (92)
Male	1 (10)	3 (8)	4 (9)
Race
White	9 (90)	33 (89)	42 (89)
Black or African American	1 (10)	4 (11)	5 (10)
Primary health insurance
Private	8 (80)	33 (89)	41 (87)
Medicare/Medicaid/other public	2 (20)	4 (11)	6 (13)
Marital status
Married/living with partner	9 (90)	27 (74)	36 (77)
Divorced/separated/widowed	0	5 (13)	5 (11)
Single-never married	1 (10)	5 (13)	6 (13)
Current employment status
Employed/self-employed full time (>30 h/week)	4 (40)	25 (68)	29 (62)
Employed part-time	1 (10)	3 (8)	4 (9)
Student, homemaker, volunteer	2 (20)	6 (16)	8 (17)
Unemployed, retired	3 (30)	3 (8)	6 (13)
Education
≤High school	1 (10)	3 (8)	4 (9)
College	4 (40)	20 (54)	24 (51)
Graduate degree	5 (50)	14 (38)	19 (40)
Recruitment source
Academic medical center/provider referral	8 (80)	18 (49)	26 (55)
Community	2 (20)	19 (51)	21 (45)
Headache features
Disease characteristics during baseline HA log
Headache days during 28-day baseline, mean (SD)	10.4 (3.1)	9.6 (3.4)	9.8 (3.3)
Migraine days during 28-day baseline, mean (SD)	4.2 (2.9)	7.3 (2.6)	6.6 (2.7)
Disease history
Years with migraine, mean (SD)	26 (19)	26 (13)	26 (14.4)
Migraine with aura	4 (40)	14 (38)	18 (38.3)
Family history of headache	7 (70)	25 (68)	32 (68.1)
Use of treatments
Current use of prophylactic treatment	8 (80)	12 (32)	20 (43)
Current use of acute medication^b	10 (100)	33 (89)	43 (92)
Experienced headache medication side effect	5 (50)	23 (62)	28 (60)
Triggers, comorbidities, and disability
Stress or letdown stress as a trigger	8 (80)	28 (76)	36 (77)
Current or past diagnosis of depression	2 (20)	15 (41)	17 (36)
Current or past diagnosis of anxiety	2 (20)	12 (32)	14 (30)
MIDAS-one month at baseline^c, mean (SD)	12.5 (9.8)	13.7 (11.5)	13.4 (11.2)
HIT-6 at baseline, mean (SD)^d	63.0 (8.0)	63.0 (7.0)	63 (7.2)

Abbreviations: HA, headache; MBSR, mindfulness-based stress reduction; MIDAS, Migraine Disability Assessment; RCT, randomized clinical trial; SD, standard deviation.
^aBaseline characteristics from the larger RCT represent participants who completed visit 2 (4 additional participants than the 33 who participated in the qualitative interviews).
^bMissing data from the larger RCT for acute medication use (n = 3 or n = 4 MBSR group).
^cMigraine Disability Assessment (MIDAS)-one month was used to decrease recall bias and improve the accuracy of the results (compared to the typical 3-month recall period).^27,31,32 Scores range 0–115, higher scores reflect greater disability, MIDAS is typically used as an average over 3 months; to facilitate interpretation of the MIDAS-one month data presented, the mean estimate results (but not the confidence intervals) can be multiplied by 3 for conversion to the typical 3 month assessment²⁷; score range for 3 month MIDAS: 0–5: little or no disability, 6–10 mild disability, 11–20 moderate disability, 21+ severe disability.
^dHeadache Impact Test-6 (36–78), higher scores reflect greater headache impact, score range: <49: little to no impact, 50–55: some/moderate impact, 56–59: substantial impact, 60+ severe impact.

Table 2. Main findings, themes, and subthemes of mechanisms of learning mindfulness through MBSR in adults with migraine.
Main finding (Table)	Themes and subthemes
Altered pain experience seen through experimental heat pain testing (Table 3)	Changed pain experience during heat pain testing • Changed perception of experimental heat pain testing • Decreased reactivity to pain during heat pain testing
	Increased migraine awareness from heat pain testing • Better understanding of migraine pain through heat pain testing • Differentiating migraine pain intensity from unpleasantness
Altered response to migraine attack (Table 4A)	Increased interoceptive awareness of migraine • Increased sensitivity to interoceptive signals resulting in earlier awareness of migraine attack • Earlier migraine attack awareness leads to altered use of medications • Use of mindfulness as an acute treatment • Use of breath during migraine attacks and with life challenges • Acknowledging and accepting pain during an attack • Interoceptive stress awareness prevents migraine trigger
Altered response to migraine attack (Table 4A)	Improved emotion regulation during migraine attacks • Awareness of, and less: fear of migraine • Awareness of, and less: pain catastrophizing Awareness of, and less: anticipatory anxiety • Decreased reactivity to migraine pain • Increased pain acceptance with decreased self-blame, guilt, and stigma • Self-compassion during migraine attacks
Altered relationship to migraine disease (Table 4B)	Increased emotion regulation of migraine disease • Migraine acceptance • Hope and empowerment • Improved self-efficacy
Altered relationship to migraine disease (Table 4B)	Increased understanding of migraine and stress • Heightened awareness of migraine and stress relationship • Improved ability to manage stress and migraine
Infusion of mindfulness skills in daily life with increased awareness of external experiences (Table 5A)	Increased awareness of self and relationship to world • Meta-awareness: Observation of external world separate from self ("self as an observer") • Broader life perspective • Nonreactive awareness through decentering and re-perceiving
	Increased awareness of sensory input • Heightened awareness and appreciation of nature • Increased exteroceptive (e.g., audio, visual, olfactory) sensory sensitivity
Infusion of mindfulness skills in daily life with increased awareness of internal experiences (Table 5B)	Increased present moment experience • Decreased autopilot mode • Breath as an anchor leads to nonreactivity
	Increased interoceptive awareness: Awareness of the body, thoughts • Increased sensitivity to interoceptive signals with embodied awareness • Metacognition: awareness of thoughts separate from self
	Increased emotion regulation • Improved emotional insight Downregulation of emotional reactivity • Earlier stress-body awareness with sensitivity to stress interoceptive signals • Improving stress response through awareness
	Increased nonjudgmental awareness Self-acceptance through nonjudgment Acceptance of life stressors Increased self-compassion
Improvement in overall well-being (Table 6)	Improvement in emotional well-being • Enjoyment and happiness • Equanimity (mental calmness, ability to relax) • Improved depressive symptoms • Improved anxiety • Prioritizing and accepting time for self-care
	Increased cognitive well-being • Awareness of mind–body integration • More focused, ability to think more clearly
	Improved social well-being: Enhanced relationships • Increased empathetic understanding and emotional literacy • More patience with self and others • Improved listening skills • Improved relationships through decreased reactivity
	Meaningful behavior changes • Improved eating and drinking habits • Improved activity level • Improved sleep hygiene
Therapeutic benefit of group experience of learning mindfulness in patients with migraine (Table 7)	Therapeutic group benefits • Decreased migraine isolation • Creation of a "safe space" • Enhanced mindfulness motivation and accountability • Empowerment through shared stories • Migraine reappraisal through understanding others' experiences

Abbreviation: MBSR, mindfulness-based stress reduction.

Table 3. Altered pain experience seen through experimental heat pain testing after learning mindfulness in patients with migraine.
Theme	Subtheme	Quotations
Changed pain experience during heat pain testing	Changed perception of experimental heat pain testing	[During the second heat pain testing after taking the MBSR class] I think maybe I perceived [the pain] differently … I feel like there were more times where there was no pain this time … I think the first time I was … calling it pain but looking back I'm like "was that really painful or was it just hot?" … [The 2nd time] I was more aware of … what was painful and what wasn't
Changed pain experience during heat pain testing	Decreased reactivity to pain during heat pain testing	[During the second heat pain testing, compared to the first, after taking the MBSR class] I did try to kind of breathe through it and not be as reactive to it this time I think. I think I was able to take a step back and really assess the values instead of just reacting to how it felt
Increased migraine awareness from heat pain testing	Better understanding of migraine pain through heat pain testing	I think that the heat study actually helped to put it in good perspective, you know to kind of have that physical example and then practice with using the scale [with my headaches] and really stopping to think that "okay yes I can feel this sensation, when does it become painful?" You know "how painful is this? How unpleasant was it?" … I think it kind of is easier to … understand after doing that
Increased migraine awareness from heat pain testing	Differentiating migraine pain intensity from unpleasantness with mindfulness	It's … not always something that is easy to differentiate [the intensity and unpleasantness of migraine pain]. I think especially with migraines because they are so painful but you get to a point where they are so painful that you think they are always that painful and sometimes they aren't that painful, they are just unpleasant. But I think that the mindfulness program helps differentiate, helps you be more aware of, "ok maybe this is not that painful maybe it's just more unpleasant." But when you have had migraines for so long you just assume that it's always that painful

Abbreviation: MBSR, mindfulness-based stress reduction.

Table 4. Altered response to migraine attack (A) and relationship to migraine disease (B) after learning mindfulness.
Theme	Subtheme	Quotations
A: Altered response to migraine attack after learning mindfulness
Increased interoceptive awareness of migraine	Increased sensitivity to interoceptive signals resulting in earlier awareness of migraine attack	• I think I recognized the headache coming on a little earlier or just that being … more aware of what's going on in my body and just accepting that this is happening and that leads me to intervene a bit earlier whereas I think before I tried to ignore it until it was building up
	Earlier migraine attack awareness leads to altered use of medications	Taking medications earlier • I think I'm able to notice certain changes in my body when a migraine is starting and so I feel like if I need medicine I can take it earlier because a lot of times I would just wait and then it would be so blown out of proportion the medication may or may not work and it would last days so I think … that has been better … I think I'm taking my medicine earlier. I'm able to notice the signs and symptoms that are … happening in my body when I have a migraine starting … Avoidance of medication • The diverting your mind from the actual pain that you are feeling … you can get through very painful periods of time … without having to take medication
	Use of mindfulness as an acute treatment	• When I know [the headache] is coming [I know] … what I need to do physically … to change its course … by either eliminating it without having to take medication … by simply paying attention to my body like most of the times when I have a headache … I am very tensed … and I am like … oh wait I need to adjust … so I take necessary measures to relax breathe focus on something else and all of a sudden it is gone … it's like it is coming and when I take necessary measures … to divert it … so it works
	Use of breath during migraine attacks and with life challenges	• I am thinking and I'm stopping, and I'm choosing now to just take a breath. And that's helping me to not just react. It helps me to put things in perspective. That's helping me, not just with my headaches, but with anything that's going on. Even if it's not a headache day, I am able to manage the day better, I am able to communicate more effectively with whoever it is I'm dealing with because I'm taking that breath, that pause. And it is becoming more automatic. I find myself now taking a breath without even thinking about it. And it's almost like a trigger that I'm getting stressed. It's like my body takes the breath for me before I mentally even realize [it]. And there are times when I take a breath consciously and say I need to take a breath. It's kind of like a dual thing that is going on
	Acknowledging and accepting pain during an attack	• Stopping for a moment to acknowledge where the pain is, what it feels like, you know what's the quality of the pain, what's the intensity of the pain—that in and of itself is being mindful. So I would say that I try harder to, not that I'm necessarily going into a formal meditation or sitting meditation, but I find myself more likely to you know getting a heat pack and putting it on my head, go lay in a quiet space, and just kind of focus on my breathing. If it's really intense, then I try to focus on that [the breathing] as opposed to consistently sitting there and thinking about the pain
	Interoceptive stress awareness prevents migraine trigger	• With actually practicing [body awareness] and noticing what's happening with your body, especially in moment of stress vs. just doing checks, you know, checking "Am I stressed? Oh no, okay." I mean doing stuff like that throughout the day, you start to notice more what's happening with your body. So I do think you pay attention and, for example in migraines, you start to catch it before it happens. Like the other day I felt like if I do not stop I'm going to have a migraine. So, I just was like, "I'm not even going to go down this path," and stopped the conversation I was having because I felt like it was going into an argument, so I just stopped, "Alight, I cannot deal with this today, I need to go be somewhere else." So, I did not get into it and never got the headache. But, I do not think I would've noticed that I was feeling like that before
Improved emotion regulation during migraine attacks	Awareness of, and less: Fear of migraine	• Part of the unpleasantness had to do with being afraid of [migraine attacks] and part of the unpleasantness came from other body sensations, it wasn't just the pain in my head it was the stomach pain and being tired because it does make you feel tired. And also the anxiety about [having headaches], being anxious about maybe having to leave work or maybe not do things at home, maybe not cook dinner. It helped me identify those factors … I felt like it was a knot that I was untying … It felt like all of these things were a big knot that was making a pain in my life and I have been able to separate them a little bit. I've been able to see this anxiety is separate from this anxiety, so let us just let that one go because really there is nothing there to be anxious about right now. There's nothing, let us just calm down and not be anxious about that right now. I was at work and I felt like I was being okay that day, so I did not have to be anxious about that. I'm starting to untie those things, to separate them and that is making it less intense
	Awareness of, and less: Pain catastrophizing	• I think that they are less intense, but I've also noticed in my last set of headaches that lasted 3 days that I just kind of felt like I could deal with it, like I can get up and I do not have to be just laid around. It's over, it's done because I do not have that fear, if you will, that this is never going to get better. "When is the pain going to go away?" I wasn't just focused on that. I was able to focus on other things like … breathing and just, "Ok, I have a headache, move on, keep going," and I was able to just deal with it better. And it did seem like the pain was less intense
	Awareness of, and less: Anticipatory anxiety	• Yes it has [changed my approach to migraine]. It's changed in that I do not think they are going to control my life and I'm not as fearful in waiting for them to come … and I know that even if it does come, I'll get through it and it will not be so terrible, I can still live through it
	Decreased reactivity to migraine pain	• Being mindful of yourself, and being responsive instead of reactive to things, and that we are always going to have the pain, and how we respond to it … I think the goal of these practices was to be aware and to notice things that happen with triggers and things with our body … When we can notice and put those into words, then we can recognize them and try to respond instead of just react. And that, I think helps, because you know these things are going to happen every day, so if you start to feel yourself tense up in your shoulders and in your neck, you can just sort of breathe in and breathe out and compensate, bring your shoulders down, take a few minutes and practice these things that we have learned. You're still going to have a headache, and you are still going to have pain, the tension is still going to be there, but these things could help to de-escalate the tension
	Increased pain acceptance with decreased self-blame, guilt, and stigma	• When I used to get migraines I'd be hard on myself. I'd put a lot of blame on myself and get frustrated with myself that I had a migraine. I mean it kind of is my fault that I had a migraine but there's not a whole lot I can do about it. But I'd get really frustrated at myself that I had another one and angry at myself that I could not get rid of it and that added stress I put on myself certainly did not make the migraine better. So, now when I get one I'm kinder to myself I do not blame myself because 99% of the time I do not put myself in a situation where I know I'm going to get one. So it's not my fault, it happens. So I'm gentler to myself and it does not add stress to the migraine, so it does not make it worse. So, it makes it less intense …
	Self-compassion during migraine attacks	• It has helped me learn to be kinder and gentler to myself when I have a migraine … when I get a migraine it's very easy to get frustrated with myself and be hard on myself because of it. Almost to the point where you blame yourself. This has helped me just be gentler with myself when I get one, which makes them easier to deal with
B: Altered relationship to migraine disease after learning mindfulness
Improved emotion regulation of migraine disease	Migraine acceptance	• [I learned to] "Let it be." Things are going to be what they are in the past, in the moment, in the future. And so, stressing about the past changes nothing, stressing about the future might change something, but probably not, and stressing in the moment just takes you out of that present moment and out of enjoying yourself. So, adding that onto headaches, [I now realize] I should not be stressed or upset with myself about having a headache the day before, or if my head hurts now, being like "Oh no my head hurts now it's going to become a headache," that's only going to get me worked up and it's not going to impact anything. So just really being able to accept things as they are and not react to everything and just kind of accept it and be like, "okay this is okay." That has been really helpful to me and I think that is kind of why I am not feeling as many headaches, I'm not getting as worked up on the inside to create the headache
	Hope and empowerment	• I think that since I have learned these exercises and being mindful … my perspectives and my life in general has changed that I have a more positive outlook and there is hope and I know now that things can be different and I am not wallowing in pain and it is a bad place to be and things are not going to change … and now I am able to see things around me and enjoy things around me … and so as a person I am someone who is more inviting because when you are in pain you do not want to talk to anybody and nobody wants to talk to you so now I think I am more open …
	Improved self-efficacy	• II absolutely think there's a mind–body connection. I mean I thought it anyway, but even more so now … a lot of it is related to the stress and tension and those sort of things and also how you think about the illness … and if you have a different view of it and that it can get better and you do have some control over it as opposed to "no, I just have to wait for something or somebody else to heal me." Then you put the control back in your hands and you do have the ability to change the outcome
Increased understanding of migraine and stress	Heightened awareness of migraine and stress relationship	• I think your migraines come from stress and worry … [meditation] literally just pulls that stress out and away. Just sends it away, whereas before it's like crap my head is starting to hurt, let us just get to the medicine cabinet, take something keep going. You're still stressed, your mind is still there and what this has done is I think about it, fix it, and then send it away
Increased understanding of migraine and stress	Improved ability to manage stress and migraine	• I really enjoyed this … it helped me cope with my stress level. In the past two months I've had a lot of things happening in my life that caused stress to increase drastically. It helped me deal with my stress in terms of being more calm, techniques I learned for relaxation, the meditation and yoga helped me to reduce my stress level and reduce my migraines by 40%. I used to get them 2–3 times a week, now I get them twice a month

Table 5. Infusion of mindfulness skills in daily life with increased awareness of external (A) and internal (B) experiences.
Theme	Subtheme	Quotations
A: Increased awareness of external experiences after learning mindfulness
Increased awareness of self and relationship to world	Meta-awareness: Observation of external world separate from self ("self as an observer")	• [I'm] much more aware about where I am any time, even [at] home, at work, out driving, in public. I went shopping on Memorial Day and there were mobs and mobs of people … I was observing how chaotic it was. I had to stand in line for a dressing room and I was like "this is very interesting" … I did not get upset about anything. I just made my choices about whether to stay or not, and I just dealt with it that way
	Broader life perspective	• "What is it that you absolutely have to do? What is it that you need to let somebody else do? What is it that you do not need to deal with?" … that's how I started looking at things, and it made my plate much smaller in terms of the things I had to deal with … So, I mean, life is different, but it's the same work … just doing things differently or perceiving them differently and realizing that I do not have to deal with all the stuff that I was turning into stress. It's just made everything much nicer
	Nonreactive awareness through decentering and re-perceiving	• It's made me more mindful or more aware of things … [I learned that] when you are mindful of things, you are mindful of unpleasant things too, not just the good things … it has helped me identify … problems [I've] been avoiding … It has given me a chance to really dissect those problems and see where I'm a problem. Is my perception part of the problem and if I do not think I can do something about that problem, can I change the way I react or respond to that problem
Increased awareness of sensory input	Heightened awareness and appreciation of nature	• I think you become more mindful of yourself and [what's] around you. I've been walking in a park for 6 years. After this walking meditation, I could not believe how many sounds there were. And I did not notice them before. I did not hear all of these birds. They have always been there, so it was a real moment for me. Wow, what a real difference, what else did I miss?
Increased awareness of sensory input	Heightened exteroceptive (e.g., audio, visual, olfactory) sensory awareness	• Sounds are louder than normal [when I'm practicing mindfulness meditation]. Someone opened the door, and it sounded like they were slamming it. Even smell too. It was heightened
B: Increased awareness of internal experiences after learning mindfulness
Increased present moment experience	Decreased autopilot mode	• I think it does help you focus better because you slow down. You're not automatic … you do not just go through the motions of doing as much as you can as fast as you can. You just slow down. [You] mindfully think about and focus on the task you are doing and not thinking about what you need to be doing 10 min from now
Increased present moment experience	Breath as an anchor leads to nonreactivity	• I am thinking and I'm stopping, and I'm choosing now to just take a breath. And that's helping me to not just react. It helps me to put things in perspective. That's helping me, not just with my headaches, but with anything that's going on. Even if it's not a headache day, I am able to manage the day better, I am able to communicate more effectively with whoever it is I'm dealing with because I'm taking that breath, that pause. And it is becoming more automatic. I find myself now taking a breath without even thinking about it
Increased interoceptive awareness: Awareness of the body, thoughts	Increased sensitivity to interoceptive signals with embodied awareness	• I definitely feel like, I find myself in moments, and I am in a situation I hate, in a plane, and I notice … "I am alright." I find myself noticing … how I feel on a more regular basis than I did before. Outside and in my body. Usually I would only do that if I had a pain. Now, after exercise, I feel great right now … Wow! I am noticing that more in general
	Metacognition: awareness of thoughts separate from self	• [Mindfulness] lets me know that just because a thought comes into my head, I do not have to think about it—I can let it go. Where before, especially if something negative had come into my mind, I would have worried about it and now I feel free to say, "you know I do not have to think about that right now," I can just let it go
Increased emotion regulation	Improved emotional insight	• I think that I've been a lot, I do not know necessarily happier, but just more aware. I have been more perceptive of my mood. So not being like "I'm upset I do not know why," but understanding why and then after being able to understand, then being able to go back to a more neutral or positive mood
	Downregulation of emotional reactivity	• [I learned to see] things happen as they are. Just being aware of it but not necessarily having an emotional response to it. Not necessarily trying to fix it, especially if it's someone else's reaction that I cannot change but I do not have to react to their reaction
	Earlier stress-body awareness with sensitivity to stress interoceptive signals	• I think in the past I would notice stress, now I am noticing the ramp up time, so now there is time to interfere with it and stop it. The early stages of stress for me feel like too much. I notice that now … It is really about stopping yourself before it's too much to come down from. Manage it before it gets to that intense level …
	Improving stress response through awareness	• I know I will not be [able to] eliminate all the stress out of my life but I can control some of it … I remove myself from situations until I can get my grasp on what I can and cannot control in that situation. Even at work I'll remove myself from situations because a lot of the stress is [at work] and I carry that stress over to home, which I did not realize I was doing
Increased nonjudgmental attitudes	Self-acceptance through nonjudgment	• There should be no judgment on ourselves. I'm very hard on myself … people pleaser, you hear those negative thoughts in your head all the time, "You're not good enough, you are a burden, you are too challenging, you are too needy, you are all these things" and standing back and reflecting and saying [instead], "Be nice to yourself, do not judge yourself as harshly as you do" … just having 8 weeks to focus on that and think about that gives you a little bit more confidence
	Acceptance of life stressors	• Like I said, my stress level has not changed in my external life, and I'm glad so I could see the impact [of the course]. I'm noticing even though the same stresses are occurring, I'm more accepting of them … I am not fighting them as much. I feel like my reaction has softened to the world
	Increased self-compassion	• I've always been good to other people but not so good to myself so I'm getting better at that. I say [to myself] "hey you are happy, you look better than you did, you got a sparkle in your eye, you walk a little bit more confident"

Table 6. Improvement in overall well-being.
Improvement in emotional well-being	Enjoyment and happiness	• I think I'm a happier more pleasant person because of it—I think being mindful of the situation you are in whether it's at work … I think I'm more engaged with them … I'm paying attention to things a lot more which makes me happier
	Equanimity (mental calmness, ability to relax)	• [I now have a] sense of stillness, calm, well-being, a sense of protection. Whatever happens matters, but it is not going to be the end of me. [I now have] a sense of being protected
	Improved depressive symptoms	• It's really shown me how to have strength in everyday and techniques to help pull me through those days as it may not be a happy day, I call them blue days. And blue days can lead to headaches if you are not careful. And this provided strategies to help through those blue days • Stress will kill you and emotions will kill you and anxiety will kill you and I've experienced depression, suicide attempts and all those things when you are in a dark hole it's so hard to climb out of [it] and I think this approach has supported the growth that I've needed as I have been progressing in my healing … that focus positively inward instead of all the negative that I've been pulling inward … I find [it] a great benefit.
	Improved anxiety	• With the mindful meditation and movements and mindful thinking, I think that's helping my stress level, helping my anxiety, helping me to focus on me and not so much [on] the stressors that are around me. And that's something I do not do a lot of, think about me … [this has had] a great benefit even more so than just going to the gym and lifting weights because [in the gym] you are focusing on your body but you are not focusing on your mind
	Prioritizing and accepting time for self-care	• I think the course forced me in a way to do more self-care … to acknowledge, "okay no you do not need to mop the floor today. It does not need to get done, it's not the end of the world." Those little things here and there to you know take time for yourself. Take time to do this meditation practice
Increased cognitive well-being	Awareness of mind–body integration	I definitely think when you get healthier mentally, it starts to affect you physically. Like when you start thinking about how can you get … healthier mentally you start looking at the physical aspect of yourself
Increased cognitive well-being	More focused, able to think more clearly	• I think it helps to clear the head, you know clear the mind and help refocus the energy … Life is busy, there's a lot going on, there's a lot of pressure. [Mindfulness] definitely kind of lifts that and moves it out of the way and allows me to just think more clearly in that moment … when I'm I come out of [meditating] I have more energy. I feel better. I'm more conscious and present
Improved social well-being: Enhanced relationships	Increased empathetic understanding and emotional literacy	• Just how I perceive certain things [has changed] like my relationship with my boyfriend and looking at things a little bit differently, like an argument we had or whatever, trying to see things from his perspective instead of just how I feel … really trying to look at things differently has helped. I feel like certain relationships are less stressful now because of that
	More patience with self and others	• I think I'm more patient now with my kids. That's a benefit for them too. I [also] think I'm more patient with myself … I think my whole demeanor in general is just calmer than it was before. [Mindfulness] just changes the way you look at anything
	Improved listening skills	• There are specific parts of my job that require me to listen and since this practice, since this training, I have learned to listen more and speak less … One patient said to me, "I really appreciate the fact that you took the time to just listen to what I had to say," and that to me was validation
	Improved relationships through decreased reactivity	• I think that … personally it has enhanced my personal relationships at home … I feel that I am not as stressed … [I am now] able to embrace the chaos without getting pulled into it and let it play out … this class has changed my demeanor … [which] affects the people in my house as well … because now they are not as dramatic … I am compassionate and kind most of the time … but since the class I have been able to catch myself when I am going to cross my line and not be so nice and be mindful. Because of practicing this you are able to pull back and say wait that is not nice
Meaningful behavior changes	Improved eating and drinking habits	• I eat less junk … when we started doing like mindful eating, that's when I started thinking "wait did I really eat that much today?" or "can I have that much of this?" or you know "if I want to be a little bit healthier … do I need to eat this?"
	Improved activity level	• Instead of just sitting on the couch I'm trying to be more involved in in my son's playtime, I'm trying to get in the extra steps here and there, parking a little further away or walking to certain places that I used to not walk to or even though it's really cold right now I've been trying to get more outdoors … I am trying to be more aware of being less stagnant
	Improved sleep hygiene	• The sleep has improved so much … I'm eating better, sleeping better, and feeling better, which is great. I really enjoyed [the class]

Table 7. Therapeutic benefits of group experience of learning mindfulness in patients with migraine.
Theme	Subtheme	Quotations
Therapeutic group benefits	Decreased feelings of migraine isolation	• You know the first week I was nervous you know meeting new people … but after that and just opening up to each other and realizing that we had so much in common with the way … we are frustrated and we were handling things and how migraines take things out of your life
	Creation of a "safe space"	• It created a sense of safety, I felt … the paradox trying to find inner space, but not feeling disconnected, I felt very supported to be able to relax and let go
	Enhanced mindfulness motivation and accountability	• With the classes you had the support system you know versus doing it at home by yourself you got that support you feel like you are not the only one you are all there motivating each other
	Empowerment through shared stories	• The support makes a big difference when you have a group of people that's walking in the same shoes and you feel like you can talk about it and support means a lot … it really does. I think that in itself is extremely beneficial as well as the strategies and techniques we were learning • I think it was beneficial to kind of hear other peoples, everyone I think had a completely different experience, but hearing those together just makes you sort of like a team, you feel like a team a little bit
	Migraine reappraisal through understanding others' experiences	• I think it increased my empathy or sympathy depending on the situation. When someone says they had a headache, it's just it's sort of blank, oh yeah you have a headache. You have no idea what a headache is. And listening to people in my class, listening to what they get as opposed to what I get and I think oh my goodness that's really bad, to get injections in their head and someone who cannot function for days or someone who's altered their life to suit their life. I am grateful that I do not have that. My headaches are bad and I perceive them as bad and they affect my life but when you look at the scheme of things of others'

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Mechanisms of Mindfulness in Patients With Migraine

Results of a Qualitative Study

Abstract and Introduction

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