If a doctor has told you your headaches are “just stress” or “just anxiety,” the short answer is this: in most people the headache is a real neurological disorder, usually migraine or tension-type headache, that happens to sit alongside anxiety or low mood. Two conditions, two diagnoses, two treatments. The label “it’s your nerves” is rarely accurate, and it often delays the care you need.
A woman in her late twenties sat in my office a while ago with a folder of three normal MRI scans. She had twenty headache days a month, took a codeine-containing painkiller on most of them, and had been on an antidepressant for two years. Every doctor had told her the same thing: stress. What she heard, understandably, was “we don’t believe you.” She had also quietly stopped going to the gym, because she was afraid exercise would set off an attack. Nobody had treated her migraine, and nobody had treated her fear.
Why “stress headache” is a claim the evidence does not support
The international headache classification (ICHD-3) recognises only two headaches that are truly caused by a psychiatric condition. One is headache that is part of somatisation disorder, a rare picture of many unexplained bodily symptoms starting before age 30. The other is headache inside a psychotic delusion. Depression, panic and generalised anxiety are listed only in an appendix, because nobody has shown that they cause the headache rather than simply coexisting with it.
The numbers explain why. Depression and anxiety are two to four times more common in people with migraine, but the link runs in both directions. Depression predicts new migraine about as strongly as migraine predicts depression, and the two share genetic risk. Association in a population is not the same as cause in you.
There is also a trap in how the stereotype was built. Specialist clinics report psychiatric diagnoses in roughly two-thirds of people with chronic tension-type headache, but population surveys find far lower rates. The picture of the anxious, tense headache patient came from the first kind of study and got applied to everyone. If you have been given that label, it is worth asking whether your actual headache pattern was ever examined. I wrote about a common version of this mix-up in Tension Headache or Migraine? Why That Label Is So Often Wrong.
When mood and headache really do travel together
Of course, anxiety and depression are real, and they matter. In my clinic I use two short questionnaires, the PHQ-9 for depression and the GAD-7 for anxiety, with anyone who has frequent headaches. They take about three minutes. A score of 10 or more on either suggests a moderate problem worth treating in its own right. I also read the last question of the PHQ-9, about thoughts of death or self-harm, before the patient leaves the room. Suicidal thoughts are more common in chronic migraine and during cluster headache bouts, and asking plainly does not raise the risk.
One narrow situation deserves mention. If your headaches appear only during depressive episodes, rise and fall with your mood, and fade when the depression is treated, then the depression is the likely driver and treating it is the right first move. That is the exception, not the rule.
What treating both actually looks like
The most useful thing I can tell you is that the headache and the mood disorder are treated in parallel, with a headache preventive chosen with your mood in mind.
First, an SSRI such as sertraline or escitalopram treats depression but does not prevent migraine. A Cochrane review of eleven trials found no benefit over placebo. If you are well-treated for depression and still have frequent migraine, you still need a migraine preventive. Some medicines can serve both purposes: venlafaxine, duloxetine, and amitriptyline at a proper antidepressant dose have a role, while CGRP-pathway drugs have no mood side effects. On the other side, topiramate and flunarizine can worsen low mood in some people, so I think twice before leaving someone on them while depression gets worse.
Second, you can take a triptan with an SSRI or SNRI. The old serotonin-syndrome warning rested on a small number of case reports, and the American Headache Society concluded the evidence did not support restricting the combination. I went through that in detail in Triptans and Antidepressants: What the Serotonin Syndrome Warning Actually Means.
Third, opioids and codeine combinations make this worse, not better. In a large US migraine study, people using opioids had nearly double the risk of their migraine becoming chronic, and heavy opioid use clustered in the most distressed patients. If you are asking for opioids, I read that as a sign that your pain and disability have not been adequately treated, not as a character flaw.
The brain tumour fear nobody says out loud
Many people with new or persistent headache are privately worried about a tumour. It is often the real reason they booked the appointment. A normal scan helps, but not for long. In a randomised trial of people with chronic daily headache, those who had an MRI were less worried at three months, but the difference had vanished by one year.
What lasts longer is a real explanation. I ask the question aloud: “Were you worried this might be a tumour?” I examine you carefully, including the back of the eyes, and tell you what I found. I give you a positive diagnosis with a name, not just a list of diseases you do not have, and I explain which changes would make me want to see you again. If you want to understand what a normal scan does and does not rule out, read Normal MRI but Still Headaches? and Is My Headache a Brain Tumor?. Repeated scans to settle recurrent anxiety tend to feed the worry rather than end it, and persistent health anxiety is treated with cognitive behavioural therapy.
Fear of the next attack can be the bigger problem
In one study of 232 people with frequent migraine, pain catastrophising (dwelling on the pain, magnifying its threat, feeling helpless) predicted disability independently of how often attacks came. Avoiding exercise, travel, or social plans, and taking painkillers “just in case,” are common results, and that last habit is a direct route to medication-overuse headache. A graded return to activity, challenging the worst-case thoughts, and CBT address this directly. For the woman I described, that combination was what finally moved the needle: after withdrawing the codeine, switching to a better-suited antidepressant and adding migraine prevention, her headache days fell from twenty to about seven a month within six months, and she stopped asking for more scans.
What I would do next
Ask for a specific headache diagnosis, not a description of your mood. Count your headache days and painkiller days for a month. Fill in a PHQ-9 and GAD-7 if you have not. And if you have been dismissed repeatedly, my guide Headache Not Getting Better? What Doctors Miss lists what a second opinion should cover. If you are having thoughts of ending your life, please contact local emergency services or a crisis line today.
From the textbook. Chapter 51, “Headache Attributed to Psychiatric Disorder, and Psychiatric Aspects of Headache Care,” of my clinical textbook Headache Medicine covers this topic in full for doctors, with the evidence and decision pathways behind it. About the book →
Next steps: (1) Download the free headache red-flag checklist. (2) Or talk to a specialist about your case.
This article is for general education and is not a substitute for personal medical advice. Sudden severe headache, weakness, confusion, or thoughts of self-harm need urgent in-person care.
By Dr. Tae-Ho Guak, MD, neurologist with over 25 years of experience treating headache.