In March 2022, the Society for Health Psychology (SfHP) hosted a continuing education webinar highlighting evidence-based psychological treatments for headache disorders presented by Drs. Elizabeth Seng, Ethan Benore, and Noah Rosen. This article aims to provide an overview of the presentation and key clinical takeaways.
Did you know?
Headache disorders include migraine (acute or chronic), tension-type, cluster, and secondary or post-traumatic headaches. Tension type-headache and migraine are amongst the most common disorders across the globe, with an estimated 38% of people experiencing episodic tension headache annually, and 12% of Americans experiencing acute migraine. (Martelletti et al., 2014, Lipton et al., 2001).
Patients with headache disorders have increased risk for depression or anxiety symptoms. For many of these patients, having a health psychologist as part of their treatment team can be an important component of receiving multidisciplinary headache care (Caponnetto et al., 2021). A health psychologist is uniquely positioned to provide a comprehensive biopsychosocial assessment for each patient, considering personality, lifestyle and behavioral factors that can greatly influence treatment response and outcomes. During treatment, the focus is on evidence-based preventive and acute treatment strategies including biofeedback, relaxation or cognitive-behavioral and stress-management approaches. There is also growing evidence for the application of mindfulness-based strategies, aerobic exercise, yoga, and modification of dietary habits in headache management (Ailani, Burch, & Robbins, 2021; Silberstein, 2000).
How do health psychologists evaluate headaches?
Biopsychosocial evaluations for headaches include the following key components:
- Symptom onset, frequency, intensity, treatment history, triggers, and qualitative descriptors
- Patient beliefs about headaches
- Current pharmacological and behavioral management strategies
- Headache-related disability, e.g., work absenteeism, social interference, emotional interference
- Perceived self-efficacy of current management strategies
- Multicultural factors
- Emotional functioning and mood status
- Lifestyle behaviors
Patients are also usually asked about the presence of premonitory symptoms of headaches such as changes in mood or thinking, sudden food cravings, yawning, GI changes, fatigue or enhanced sensory sensitivities.
Self-monitoring via headache diaries are a simple yet effective method of self-monitoring that help assess efficacy of treatment and therapeutic agents as well as identifying person-specific factors related to headache. To use a headache diary, patients are often asked to consistently track the quality and quantity of a headache episode, preventive strategies, triggers, medication use, coping methods, and the impact of pain. Apps such as Migraine Buddy or Migraine Monitor can be helpful resources to help patients track symptoms with ease to increase the likelihood of self-monitoring.
What goals can patients set for behavioral treatment?
Common patient goals for treatment are to reduce the frequency and severity of headaches, to improve functioning and reduce headache-related impairments, to bolster self-efficacy in being able to self-manage headache symptoms, and to reduce headache-related or overall psychological distress.
The initial session typically begins with building rapport by acknowledging the often invisibility of chronic pain and validating the patient’s suffering. This session may also include an overview on headache education such as basic headache pathophysiology, diagnostic categorizations, migraine threshold theory (e.g., the threshold at which people are at based on various individual precipitants or triggers that determines likelihood of migraine), and headache or migraine stigma.
Subsequent sessions will focus on techniques aimed at lowering physiological hyperarousal in response to pain such as deep breathing, autogenic training, guided imagery and progressive muscle relaxation, which are key to helping patients modulate their stress and decrease the “fight vs. flight” activation. Biofeedback, a method by which patients receive real-time electronic feedback on their bodily functions, can help patients develop awareness of how their psychology influences biological processes, leading to greater voluntary control over previously involuntary bodily functions.
Sessions will also include training on cognitive restructuring, a powerful tool to modify the emotional, behavioral, and physiological responses to headache by helping patients become aware of unhelpful automatic thoughts in reaction to their pain. Modifying a patient’s pain-related beliefs and behaviors can result in improved emotional functioning, decreased physiological hyperarousal, and greater engagement in activities.
Patients will also learn how their lifestyle behaviors such as sleep habits, dietary patterns, and level of physical activity can influence their headache episodes and ways to improve these areas in order to enhance treatment outcomes.
Ailani, J., Burch, R. C., & Robbins, M. S. (2021). The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache, 61(7), 1021-1039. https://doi.org/10.1111/head.14153
Caponnetto, V., Deodato, M., Robotti, M., Koutsokera, M., Pozzilli, V., Galati, C., Nocera, G., De Matteis, E., De Vanna, G., Fellini, E., Halili, G., Martinelli, D., Nalli, G., Serratore, S., Tramacere, I., Martelletti, P., & Raggi, A. (2021), Comorbidities of primary headache disorders: A literature review with meta-analysis. The Journal of Headache and Pain, 22(71). https://doi.org/10.1186/s10194-021-01281-z
Lipton, R. B., Stewart, W. F., Diamond, S., Diamond, M. L., & Reed, M. (2001). Prevalence and burden of migraine in the United States: Data from the American Migraine Study II. Headache, 41(7), 646-657. https://doi.org/10.1046/j.1526-4610.2001.041007646.x
Martelletti, P., Birbeck, G. L., Katsarava, Z., Jensen, R. H., Stovner, L. J., & Steiner, T. J. (2013). The Global Burden of Disease Survey 2010, Lifting The Burden and thinking outside-the-box on headache disorders. Journal of Headache Pain, 14. https://doi.org:.10.1186/1129-2377-14-13
Silberstein, S. D. (2000). Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 55(6), 754-762. https://doi.org/10.1212/wnl.55.6.754