Behavioral Interventions for Management of Primary Head Pain
When patients seek medical consultation for headaches, they often feel like failures because, despite efforts at self-treatment, nothing seems to provide relief. And they are usually concerned that their lives are being ruined by disabling headaches. They cannot make plans for fear of being unable to follow through or they may recognize that their productivity at home, work, or school is diminishing. A few may wonder if they have a brain tumor. Of course, they expect to receive a thorough physical and neurological examination, appropriate lab tests, and prescription medication for their pain. In addition, however, they need to learn how to regain control over their condition and their lives. Because disabling headaches affect the person's entire system and the ability to function, the treatment plan needs to include behavioral as well as pharmacological measures.
Behavioral intervention may be as simple as education about primary headache disorders. If anxiety or depression is complicating the headache pattern, cognitive behavioral therapy may be indicated. For those patients who complain of cold hands and cold feet and are having an increasingly difficult time in meeting the demands of home, work, or school, relaxation training and biofeedback are useful. Behavioral options help patients become involved in their own treatment, which greatly assists compliance with the management plan and increases satisfaction with treatment. In addition, behavioral interventions increase the efficacy of the medications used to treat disabling headaches. When patients meet certain criteria for therapy (see Table below), behavioral treatments can be used to reduce headache frequency, severity, associated disability, and the need for medication at the same time that they instill a sense of control over headache attacks. This review, directed to the primary care provider, covers the theory and application of behavioral approaches in the management of primary headache disorders.
| Identifying Patients for Behavioral Interventions |
- Preference for nonpharmacologic interventions
- Poor tolerance of pharmacologic treatment
- Medical contraindications to pharmacologic treatments
- Inadequate response to pharmacologic treatment
- Pregnancy, planned pregnancy, or nursing
- History of excessive use of analgesics or other acute medications
- Life stress, defiant coping skills, or comorbid psychological disorder
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Cognitive Behavioral Therapy (CBT)
CBT combines cognitive therapy with behavior therapy. Individuals identify, through the help of a therapist, certain thinking patterns that are exacerbating the physical condition, in this case disabling headaches. By these habitual, often automatic thoughts, distortions occur in perception, making individuals feel anxious, depressed, or angry, which leads to self-defeating behaviors. The behavioral part of therapy teaches patients to stop these habitual reactions to troublesome events. It also focuses on methods to calm the body and mind for enhanced productivity, creativity, and a sense of relaxation and control. Stress management training is a type of cognitive behavioral therapy that teaches headache patients how to cope with everyday stressors in order to avoid precipitating, exacerbating, or prolonging headache attacks. Ideally, patients treated with CBT learn and adopt strategies for dealing with their headache-causing stressors and stressful situations. The duration of CBT depends on the individual, but a course of treatment typically lasts from 3 to 12 sessions.
A wealth of evidence supports the use of CBT in the management of primary headache. For example, in a recent review of 7 studies assessing the clinical benefits of CBT in migraine patients, Campbell et al estimated an average of 49% improvement in headache activity (a composite score of headache frequency, intensity, and/or duration). Similarly, among tension-type headache patients, CBT can reduce headache activity by almost 50%. Judicious patient selection is crucial, however, as one study found that patients with chronic head pain are minimally responsive to cognitive behavioral interventions. Combining behavioral modalities may also be helpful, particularly if a patient does not respond to CBT alone. One group of investigators combined cognitive behavioral training with biofeedback and achieved an average of 38% improvement in headache activity. Examples of cognitive behavioral approaches include assertiveness training, cognitive restructuring, and coping skills. These approaches may increase treatment compliance among headache patients.
Assertiveness Training
Some headache patients, especially migraineurs, have low self-esteem and have a difficult time saying no, especially to family members, because of fear of rejection, abandonment, or an aggressive confrontation. Many patients in this situation might benefit from assertiveness training.
Assertiveness training involves 4 steps:
- Identify when a behavior is being asked that the person does not want to do - usually signaled by feelings of guilt, anxiety, ignorance, or dread
- Practice saying no in unimportant situations, such as to a cashier in a supermarket
- Say no to those who will understand, such as a friend
- Finally, say no to the person who demands behaviors that produce negative feelings
The process of identifying and mastering these issues can significantly improve a headache patient's condition.
Case Study
Christina is relaxing at home, tired after a busy day at the office. The phone rings, and she thinks, "Mom's nightly phone call is early." After reporting to her mother the events of the day, she has to cut the call short because of a headache that is developing behind her right eye. These headaches are starting to happen more frequently, at least 4 times a week, and they usually occur after speaking to her mother.
Recommendations
The guideline authors advised Christina to purchase an answering machine and to screen her phone calls. They also suggested that she return the phone calls at her convenience. Since her mother usually slept late, the authors recommended that she call her mother at 7 a.m. (when Christina first woke up), rather than wait for her mother to contact her. Within a week, her mother stopped the practice of nightly phone calls. Soon afterwards, Christina's headache frequency decreased to 1 or 2 per month.
Cognitive Restructuring
Cognitive restructuring is identifying and changing negative self-talk that occurs automatically. With a recurrent, episodic pain syndrome such as headache, the individual may begin to feel like a victim, helpless, at the mercy of the attack. In cognitive restructuring, a physician or a psychologist and the patient create affirmations to replace negative self-talk. Getting patients to make statements such as "I deserve health" to replace "I have to suffer like my mother" is an important first step in cognitive restructuring.
Some migraineurs feel like failures because they cannot control their attacks. They judge themselves as unreliable because they cannot meet their responsibilities and sometimes let others down. Disabling headaches prevent them from doing what they want to do but may also be punishment for being such a "bad" person. A powerful affirmation for migraineurs is "I forgive myself for being imperfect."
Case Study
With the approach of her menstrual period, Phyllis feels anxious and dreads this time of the month. She knows she will have to spend a day or two in bed in a dark room, making excuses for not being able to work, to care for her family, or to be with friends. Her mother used to suffer the same way until she went through menopause. Phyllis wonders whether a hysterectomy would get rid of these sick headaches.
Recommendations
Instead of accepting that disabling headaches are inevitable and that she is a failure who is destined to be miserable, Phyllis was asked to recite affirmations ("I deserve health and harmony") to counteract the negativity of her defeatist thinking. In addition, the guideline authors worked to develop ways to reduce the frequency, severity, and duration of her attacks. The authors instructed her that taking a nonsteroidal anti-inflammatory drug (NSAID) beginning 2 or 3 days before the anticipated menstrual migraine might reduce the intensity of the attack or prevent it altogether. Emboldened by the success of treatment, Phyllis developed a more positive outlook. Finally, the authors initiated a program of exercise and biofeedback training, which further shortened the duration of her menstrually-related attacks.
Coping Skills
Change is a common risk factor for disabling headaches. Once headache patients recognize this trigger, they need to bolster their vulnerable nervous systems with positive behaviors, such as exercise, recreation, and self-nurturing activities. With these skills, individuals find that control over headaches generalize to other aspects of life. No longer do their headaches occur "out of the blue."
Case Study
It's allergy season and Fred seems to get a headache every day. He also just started a new job and is learning the business. He used to exercise regularly, but recently he has been skipping his morning walk, sometimes for a week at a time. Lately, he seems to function at only one speed, full steam ahead. At work, he takes an over-the-counter remedy and closes his office door to get away from the pressure cooker at the office.
Recommendation
The guideline authors recommended that Fred find time to relax in his office, using mental imagery to push his worries about his demanding boss from his mind. The authors instructed him to visualize himself in successful professional situations, such as winning a big contract for a project he developed and presented to a client. The authors also pointed out that he needed to reestablish the routine of a brisk workout before he leaves for work. With these coping measures in place, the authors were able to work with Fred to reduce his attack frequency and severity.
Relaxation Training
Relaxation training has been recognized as an effective therapy for more than a century. In headache management, as with other nonpharmacologic approaches, clinicians most often use relaxation training as a prophylactic treatment. Three types of relaxation training are still widely used today: progressive muscle relaxation, autogenic training, and meditation (see table below); it is important to be familiar with each of the types and to understand when and how to apply them in clinical practice. Patients can usually be taught to incorporate 20 to 30 minutes of relaxation exercises into their daily routine within 10 treatment sessions, although sometimes fewer sessions are required.
Research supports the use of relaxation training in the treatment of migraine and tension-type headache. Several studies have shown that migraine patients who are taught to use relaxation techniques have been able to reduce their headache activity by about 40%. Significantly, thermal biofeedback combined with relaxation training can be less effective in migraine prevention than relaxation alone. Tension-type headache patients have been able to use relaxation training to cut headache activity by about 40%, similar to rates seen in migraine. However, when investigators combined relaxation techniques with electromyographic biofeedback, they improved the rates of reduction of tension-type headache activity to about 50%.
| Types of Relaxation Training |
- Progressive muscle relaxation: Alternately tensing and relaxing muscle groups throughout the body
- Autogenic training: Using self-instructions of warmth and heaviness
- Meditation: Using a silently repeated word or sound
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Biofeedback
In biofeedback, which uses principles derived from Ayurvedic medicine, headache patients learn to monitor and regulate physiologic functions in order to gain control of their condition. There are 2 major types of biofeedback instruction: thermal (also called hand-warming) and electromyographic (EMG). Thermal biofeedback records skin temperature from a finger thermometer. EMG biofeedback measures electrical activity in the muscles through an electrode. The downside to EMG biofeedback is that the patient must return to the office to practice with the EMG machine.
Biofeedback essentially instructs patients to regulate their nervous system to respond to stressors through the parasympathetic rather than the sympathetic system. To train headache patients well enough in biofeedback techniques to realize benefits requires repetitive treatment sessions. Patients need to practice at least 10 minutes daily; otherwise, more sessions are required with a therapist.
When practiced regularly, biofeedback techniques can achieve significant reductions in headache activity. In subjects with migraine, EMG biofeedback has reduced headache activity by approximately 55%; thermal biofeedback, when combined with relaxation training, reduced headache activity by about 35%. Among tension-type headache patients, EMG biofeedback cut headache activity by around 50%. Among tension-type headache patients, EMG biofeedback, when combined with relaxation training, reduced headache activity slightly less than EMG alone.
Both types of biofeedback training can be effective in headache management but only when used in appropriate patients. For example, both migraine and tension-type headache patients can use EMG and thermal techniques, but cluster patients find that relaxation triggers a headache during their cluster period. Although biofeedback techniques are employed mainly as a preventive treatment, some patients may be able to use them to modify the course of an existing headache, such as during prodrome or mild headache, thereby reducing or eliminating the need for acute medication.
In a 3-year study that compared the effectiveness of ergotamine tartrate and relaxation-biofeedback training, both methods reduced headache activity by 50% or more. However, over time, the subjects treated with ergotamine were more likely to have obtained additional medical treatment for headaches and to use either prophylactic or narcotic medications.
Behavioral interventions for primary headaches have their origins in the pioneering work of Wolff, whose careful observations led him to describe how thoughts, behaviors, and bodily reactions evolve in response to stress to induce migraine attacks. Green et al made the seminal observation that headache sufferers tended to have finger temperatures around 70 degrees Fahrenheit (F). By contrast, individuals without severe headaches recorded finger temperatures of about 85 degrees F.
With recent work suggesting that migraine and tension-type headache are manifestations of a continuum of head pain (as opposed to distinct disease states), Wolff's ideas are equally persuasive for tension-type patients. Thus, the available research on nonpharmacologic headache therapies suggests a common-sense approach to headache management, in which risk factors are avoided and health-promoting, protective factors are encouraged (refer to Figure 8.1 of the original guideline document). Teaching headache patients to regulate their reactions to stressors with CBT, relaxation training, biofeedback - or some combination of behavioral techniques - can improve overall therapeutic outcomes by reducing headache activity as well as the need for acute and preventive medications.
