BEHAVIORAL AND NONPHARMACOLOGIC TREATMENTS OF HEADACHE

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A TALE OF TWO MIGRAINES

It was the best of times.
It was the worst of times.
It was the age of serotonin and the 5-HT 1B/1D agonists.
It was the age of analgesic rebound and medication abuse.
It was the epoch of nonpharmacology.
It was the epoch of noncompliance.
It was the season to function heroically.
It was the season of disability.
It was the spring of hope.
It was the winter of comorbid depression.44

BEHAVIORAL TREATMENT

Despite the explosive growth of migraine-specific drugs, behavioral medicine remains important in the comprehensive management of headache. Some patients prefer nonpharmacologic treatment. The effective management of the behavioral issues identified in the parody of Dickens' A Tale of Two Cities—analgesic overuse, noncompliance, disability, and psychiatric comorbidity—can be critical to treatment efficacy for the complex or difficult patient. The most potent pharmaceutical treatments are not

COGNITIVE-BEHAVIORAL ANALYSIS

Behavioral therapists often perform a functional analysis of headache activity, attending to the interaction of environmental events, the patient's behavioral response, and the resulting impact of that behavior.42, 53 Behavioral interviewing, using a simple A-B-C analysis as a guide, helps to individualize treatment and identify barriers to improvement:

  • A = Antecedents: Events that precede the periods of increased headache. They include external risk factors, triggers, and aggravators

MULTIAXIAL BEHAVIORAL ASSESSMENT

The author and colleagues have proposed a multiaxial assessment format as a tool to address the relevance of behavioral factors in the headache patient,46 modeled after the multiaxial psychiatric diagnostic system of the American Psychiatric Association (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV]).1 In its current form, there are five axes or dimensions:

  • I

    Headache diagnosis, frequency, severity

  • II

    Analgesic or abortive use, overuse, and abuse

  • III

    Behavioral and stress-related

Relaxation Therapy and Biofeedback

Relaxation-based therapies include autogenic training (self-statements about relaxing muscles, warming the hands, and quieting the mind), muscle tension-relaxation exercises, meditation, and hypnosis. Biofeedback usually combines relaxation with monitoring and feedback of surface electromyography (EMG) in the head or neck or circulation changes as measured by hand temperature.10, 78 Although EMG feedback is helpful for migraine and TTH, its benefits have not been shown to be related directly to

FUTURE DIRECTIONS

The effectiveness of behavioral treatments for episodic headache,10, 78 even when taught in cost-efficient minimal contact treatment programs,69 suggests a potentially expanded role as a primary intervention for migraine and TTH, particularly for patients with an interest in taking an active role in their own care and minimizing medication.44 Most of the published research on behavioral treatment is relaxation based, with attention to assisting the patient in recognizing and altering

SUMMARY

Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol.

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    Address reprint requests to Alvin E. Lake III, PhD, Michigan Head-Pain and Neurological Institute, 3120 Professional Drive, Ann Arbor, MI 48104. e-mail: [email protected]

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    Michigan Head-Pain and Neurological Institute, Ann Arbor, Michigan

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