What Pain Acceptance Really Means

A few years ago, a physician colleague of mine asked me a version of this question at a conference:

“I want to send my patients to see you for acceptance and commitment therapy (ACT), but it just sounds so bad. Do you want me to tell them they just have to get used to having migraine? That they should just accept it?”

Whenever I wade into this murky territory of “pain acceptance” as it applies to people with migraine, I stumble over the difference between “psychology speak” and plain English. Our recent mechanistic analysis of a mindfulness-based clinical trial helps provide some context for what we mean by “pain acceptance” in migraine and what components may be most important for improving migraine management.

Pain acceptance has two components: the extent to which you engage in life activities even though you have pain, and the “pain willingness,” or the extent to which painful experiences are seen as a normal (if unpleasant) part of life (versus being totally unacceptable and to be avoided at all costs). In the context of migraine, pain acceptance works like this: If you have high-activity engagement, you still go to your cousin’s wedding, and if you have a migraine attack there, you manage the symptoms as best you can. Note that this is activity engagement in spite of migraine symptoms or the potential for a migraine attack if you engage in the activity. It is not how active you are overall in life; you don’t let migraine stop you from doing things you think are important.

If you have high pain willingness, you don’t see every migraine attack as unacceptable. You’re willing to live with migraine as part of your life (ideally a smaller part) and don’t see the complete elimination of migraine attacks as the only acceptable treatment goal. You just want the role migraine plays to be lessened by effective treatments.

Our recent clinical trial demonstrated that increases in pain acceptance over the course of a mindfulness-based intervention for migraine were associated with reductions in disability, suggesting that changing pain acceptance may be a way that these mindfulness treatments work. But when we looked closer, we found something really interesting: It was improvements in activity engagement that carried the day. As people learned mindfulness and improved their skills of nonjudgmental awareness of the present moment, they participated more in valued life activities despite migraine symptoms. That re-engagement in life, more than “pain willingness,” helped patients with migraine feel better over the course of the trial.

The quote commonly used in acceptance-based approaches, “Pain is inevitable, but suffering is optional,” just doesn’t hit as well for painful diseases that are simply not inevitable. It is certainly inevitable that every person in their life experience some amount of emotional pain: the loss of a job, a parent, or a relationship. It is likely inevitable that every person, at some point in their life, experiences some amount of muscle pain as well. But it is simply not the case that migraine attacks are inevitable. The majority of people in the world will never have migraine disease. Over a lifetime, 43% of women and 18% of men will have migraine disease; that's less than half, even for women. It is reasonable for patients to seek aggressive treatment options that provide them with relief. But to the extent that modern medicine is still working toward effective treatment options and that the efficacy of current options is highly variable among people with migraine, people with migraine currently can expect that migraine disease will be a part of their lives, even when on “effective” prevention and acute treatment options.

So what does “pain acceptance” mean for migraine? People with migraine engage in activities that are meaningful and bring value to their lives to the extent possible, even when experiencing some types of symptoms. People with migraine recognize that migraine is a neurologic disease and actively seek treatment options to reduce their symptoms while also acknowledging this fact: As a person with migraine when I wake up tomorrow, it’s possible I’ll have an attack. And I have to be ready.

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