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What’s the Nocebo Effect and How Does It Influence Migraine?

Living Well

January 26, 2024

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Photography by Israel Sebastian/Getty Images

Photography by Israel Sebastian/Getty Images

by Nandini Maharaj

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Medically Reviewed by:

Francis Kuehnle, MSN, RN-BC

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•••••

by Nandini Maharaj

•••••

Medically Reviewed by:

Francis Kuehnle, MSN, RN-BC

•••••

•••••

The nocebo effect is when negative expectations lead to a negative outcome. This can make a medication less effective or increase side effects. You can prevent the nocebo effect with cognitive restructuring.

“Relax your arm. This might sting a little,” the nurse says, right before I get my flu shot.

I’m not usually afraid of needles, but a disclaimer about a stinging sensation makes me feel the opposite of relaxed. It might even make getting the shot worse.

Experiencing heightened pain after you’re told to expect it is an example of the nocebo effect. This effect can also happen when you anticipate negative side effects of a medication.

The “nocebo effect” comes out of the “placebo effect.” While the nocebo effect can worsen your symptoms, the placebo effect can help you feel better by relieving symptoms. An example of the placebo effect is feeling relaxed after taking a sugar pill that you were told has an anti-anxiety effect.

So what does the nocebo effect have to do with migraine treatment and symptom management?

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The nocebo effect and migraine

Based on what’s known about the nocebo and placebo effect, there seems to be a connection between what you expect from treatment and the resulting side effects.

Ideally, migraine treatments can help alleviate symptoms and prevent future episodes. However, if you expect a medication to be ineffective, you’re more likely to see less improvement in your condition.

This is due to the nocebo effect, which occurs when negative expectations lead to negative outcomes. This can happen specifically in the case of migraine treatment.

An example is believing that a medication will make you less alert even when it doesn’t measurably affect your ability to focus, learn, or recall information.

A personal example

When I was diagnosed with migraine, my doctor recommended taking acetaminophen for pain relief. He warned that the medication could be less effective if I waited too long to take a pill after the onset of migraine symptoms.

He also advised me that taking this medication for longer than a few days could lead to unwanted side effects, like stomach pain or tenderness. Being aware of these risks influenced how I use this medication.

For instance, sometimes I’ll take acetaminophen sooner than needed instead of trying other pain relief strategies like taking a break from work or getting fresh air.

After taking this medication for a few days, I’m more likely to attribute any sign of stomach upset to the side effects of acetaminophen. As a result, I could be missing or overlooking symptoms that aren’t related to the medication.

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Can negative thinking affect your health?

Your thoughts can affect your mental and physical health. Just imagine the stream of thoughts that run through your mind when you’re worrying about a job interview or waiting in a long line.

You might be saying to yourself, “I’m not qualified for this job,” or “I don’t know why I bothered to apply.” Or you might be in line thinking, “I have so much to do, I’ll never get it done on time.”

Anxious thoughts like these can lead to an increase in heart rate and blood pressure. Stress can also affect the quality of your sleep and your immune system’s ability to fight infection.

The nocebo effect works in a similar way.

For instance, when I’m watching TV commercials about migraine medications. I get pulled in by the promise of symptom relief, but I’m wary of the long list of unwanted side effects flashing across the screen. They often sound worse than the condition itself!

These mixed feelings of hope for relief and apprehension about side effects can lead to uncertainty or even anxiety about taking medication. This could potentially undermine the body’s ability to benefit from that medication.

What situations lead to the nocebo effect?

The way your doctor presents information about the risks of a particular treatment can influence your expectations.

The nocebo effect is more likely to happen if you:

  • have a history of anxiety or depression
  • experience fear of pain
  • have personality traits like pessimism
  • distrust doctors
  • experience negative interactions with the healthcare system
  • have read about or experienced unwanted side effects in the past
  • face high costs of medication or medical procedures
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What can you do if you experience the nocebo effect?

If you have concerns about a medication, it’s a good idea to do your research in addition to speaking with your doctor. It can be helpful to come prepared with a list of questions or have someone come with you to your appointment for moral support.

You can also follow the tips below.

Improve communication

Despite how unpleasant it feels, the nocebo effect presents an opportunity to improve communication with your doctor. If they mention side effects like nausea or insomnia, you can probe further and find out how common these side effects are.

Setting your mind at ease can make all the difference.

Minimize unpleasant effects

You can ask about strategies to minimize side effects, like:

  • What is the optimal time to take the medication?
  • Should I take it with or without food?
  • What do I do if I miss a dose?

This can give you a sense of control and agency over your medication experience.

Actively de-stress

Since stress can make you feel worse, actively seek and engage in activities that help you feel calm, safe, and relaxed.

Whether it’s yoga, knitting, or Netflix, find ways to unwind and give yourself time to de-stress — every day, if possible.

Reframe your thinking

Learning to reframe your thoughts can lead to more positive outcomes.

For example, instead of saying, “Medications never work for me,” you could try saying, “I’m going into this with an open mind, and I’m hoping for the best.”

You can keep a journal of negative thoughts about your medication and actively rewrite them as they arise. This is one example of cognitive restructuring, a therapeutic technique that can help you change negative thinking patterns.

Frequently asked questions

Have more questions about the nocebo effect and migraine? Get the facts below.

Is the nocebo effect real?

Research from 2019 notes that the nocebo effect is a common phenomenon that may have potentially negative consequences for the results of clinical treatment and trials.

The researchers also found that the nocebo effect is under-recognized by clinical researchers and clinicians when compared with the placebo effect.

How common is the nocebo effect?

The nocebo effect is common in clinical trials but is less often monitored and recorded compared with the more familiar placebo effect.

An older 2009 research review of 73 anti-migraine clinical trials and 69 studies noted that it was common for participants taking a placebo to report a high frequency of side effects, even though they weren’t taking an active medication.

While it’s difficult to estimate exactly how often the nocebo effect occurs, even in controlled studies, it’s nearly impossible to measure it in real-world circumstances.

What causes the nocebo effect?

Negative expectations of treatments can lead to the nocebo effect.

The source of these expectations may be health advice received from friends or social media, offhand or insensitive comments by medical staff, as well as ideas about medical care that come from upbringing.

Your general life outlook and mental health also play a role. People who experience anxiety, depression, fear of pain, and pessimism are more susceptible.

The nocebo effect also works to strengthen negative beliefs, as any undesirable treatment outcome automatically affirms and reinforces any negative expectations about it.

How do you reverse the nocebo effect?

Similar to the way a person can be conditioned to expect a negative response, they can learn to associate an unpleasant situation with a positive response.

For example, one 2019 study found that verbal suggestions can be used to reverse expectations that a medication causes itchiness.

Therapeutic tools like cognitive restructuring, where negative thoughts are addressed and repatterned, can also be beneficial.

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Takeaway

The nocebo effect occurs when negative treatment outcomes follow negative expectations. In some cases, it can make treatment seem less effective or more likely to cause negative side effects.

Interactions with healthcare professionals likely play a role in the nocebo effect, but experts are still learning what’s behind this phenomenon.

Medically reviewed on January 26, 2024

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About the author

Nandini Maharaj

Nandini Maharaj, PhD is a freelance writer covering health, work, identity, and relationships. She holds a master’s degree in counseling and a PhD in public health. She’s committed to providing thoughtful analysis and engaging wellness content. Her work has appeared in HuffPost, American Kennel Club, Animal Wellness, Introvert, Dear, and POPSUGAR. She is a dog mom to Dally, Rusty, and Frankie. Find her on Twitter or her website.

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