Behavioral management of recurrent headache: three decades of experience and empiricism

In the past three decades, behavioral interventions (chiefly relaxation, biofeedback, and stress-management) have become standard components of the armamentarium for management of migraine and tension-type headaches. Meta-analytic literature reviews of these behavioral interventions have consistently identified clinically significant reductions in recurrent headache. Across studies, behavioral interventions have yielded approximately 35–50% reduction in migraine and tension-type headache activity. Although we have only recently begun to directly compare standard drug and nondrug treatments for headache, the available evidence suggests that the level of headache improvement with behavioral interventions may rival those obtained with widely used pharmacologic therapies in representative patient samples. In recent years, some attempts have been made to increase the availability and cost effectiveness of behavioral interventions through alternative delivery formats and mass communications. Recent developments within diagnosis and classification are summarized, pointing out implications for behavioral researchers. Select future directions are discussed, which include impact of the triptans, cost and cost effectiveness, and integration of behavioral treatments into primary care settings, the place where the great majority of headache sufferers receive treatment.     

A retrospective,follow-up study of biofeedback-assisted relaxation therapy in patients with posttraumatic headache

Although biofeedback in the treatment of migraine and tension-type headache has been widely researched, there is little research examining biofeedback therapy in posttraumatic headache (PTH). In this retrospective study, 40 subjects with PTH who had received biofeedback-assisted relaxation at our headache clinic were questioned at least 3 months following the completion of therapy. Subjects were queried about improvements in headache, increases in ability to relax and cope with pain, and overall benefits, lasting effectiveness, and continued use of biofeedback in daily life. Results indicate 53% reported at least moderate improvement in headaches; 80% reported at least moderate improvement in ability to relax and cope with pain; 93% found biofeedback helpful to some degree; 85% felt headache relief achieved through biofeedback had continued at least somewhat; and 95% stated they were continuing to use biofeedback skills in daily life. A correlation analysis revealed a negative relationship between response to biofeedback and increased chronicity of the disorder. In other words, the more chronic the disorder, the poorer the response to treatment. A stepwise regression analysis found that chronicity of the disorder and number of treatment sessions significantly affected response to treatment. Data suggest that biofeedback-assisted relaxation should at least be considered when planning treatment strategies for posttraumatic headache.We wish to express our appreciation to Sandra Tomlinson Becky Kinloch, and C. M. Bundrick for their assistance in this project.     

Computer Animated Relaxation Therapy in Children Between 7 and 13 Years with Tension-Type Headache: A Pilot Study

This pilot study evaluated the effect of computer animated relaxation therapy in children between 7 and 13 years with tension-type headache and the children’s experiences with the therapy. The therapy consisted of an uncontrolled nine-session course in modified progressive relaxation therapy assisted by computer animated surface EMG provided from the trapezius muscles and with the physiotherapist as a participant observer. Outcome measures were (a) headache frequency and intensity, (b) pericranial tenderness, (c) tension patterns, and (d) evaluations assessed at baseline and at 3 months follow up. Nine children, mean age 10.9 (SD 1.7) years, diagnosed with frequent episodic or chronic tension-type headache completed the course. The results showed a mean improvement of 45% for headache frequency at 3 months follow up versus baseline and a significant reduction in headache frequency for all participants and in Total Tenderness Score for children with frequent episodic tension-type headache. The children expressed a growing understanding of body reactions and an acquired ability to deactivate and regulate these reactions. Computer animated SEMG seems an applicable learning strategy for young headache sufferers. This study suggests that children below the age of 13 need both the dialog and guidance from a participant observer in order to achieve body awareness.     

Comments on The Failure of Intensive Self-Regulatory Treatment with Chronic Daily Headache

Nonpharmacological therapy of primary headache conditions including chronic daily headache (CDH) is not well-studied. Barton and Blanchard report on their experience with intensive self-regulatory treatment in a cohort of patients with CDH. This negative trial provides preliminary observations that need further investigations in controlled, adequately powered clinical study.     

Headaches in Multiple Sclerosis Patients Might Imply an Inflammatorial Process

Recent studies on Multiple Sclerosis (MS) pathology mention the involvement of “tertiary B cell follicles” in MS pathogenesis. This inflammatory process, which occurs with interindividually great variance, might be a link between MS pathology and headaches. The aim of this study was to detect the prevalence of headaches and of subtypes of headaches (migraine, cluster, tension-type headache [TTH]) in an unselected MS collective and to compile possibly influencing factors. Unselected MS patients (n = 180) with and without headache were examined by a semi-structured interview using a questionnaire about headache, depression and the health status. Additionally clinical MS data (expanded disability state score [EDSS], MS course, medication, disease duration) were gathered. N = 98 MS patients (55.4%) reported headaches in the previous 4 weeks. We subsequently grouped headache patients according to the IHS criteria and detected 16 (16.3%) MS patients suffering from migraine (migraine with aura: 2 [2%]; migraine without aura: 14 [14.3%]), 23 (23.5%) suffering from TTH and none with a cluster headache. Thus, headaches of 59 (60.2%) MS patients remained unclassified. When comparing MS patients with and without headaches significant differences in age, gender, MS course, physical functioning, pain and social functioning occurred. MS patients with headaches were significantly younger of age (p = 0.001), female (p = 0.001) and reported more often of a clinically isolated syndrome (CIS) and relapsing/remitting MS (RRMS) instead of secondary chronic progressive MS (SCP). EDSS was significantly lower in MS patients suffering from headaches compared to the MS patients without headaches (p = 0.001). In conclusion headache in MS patients is a relevant symptom, especially in early stages of the MS disease. Especially unclassified headache seems to represent an important symptom in MS course and requires increased attention.     

Comments on Barton and Blanchard

The paper by Barton and Blanchard (2001) posits that intensive self-regulatory treatment may be ineffective for chronic daily headache. This commentator has concerns about the lack of homogeneity of population, problems with the diagnostic criteria utilized, the validity of the medication index, and issues with analgesic rebound.     

Application of ICHD-II Criteria in a Headache Clinic of China

Background

China has the huge map and the largest population in the world. Previous studies on the prevalence and classification of headaches were conducted based on the general population, however, similar studies among the Chinese outpatient population are scarce. This study aimed to analyze the characteristics of 1843 headache patients enrolled in a North China headache clinic of the General Hospital for Chinese People''s Liberation Army from October 2011 to May 2012, with the International Classification of Headache Disorders, 2nd Edition (ICHD-II).

Methods and Results

Personal interviews were carried out and a detailed questionnaire was used to collect medical records including age, sex and headache characteristics. Patients came from 28 regions of China with the median age of 40.9 (9–80) years and the female/male ratio of 1.67/1. The primary headaches (78.4%) were classified as the following: migraine (39.1%), tension-type headache (32.5%), trigeminal autonomic cephalalgias (5.3%) and other primary headache (1.5%). Among the rest patients, 12.9% were secondary headaches, 5.9% were cranial neuralgias and 2.5% were unspecified or not elsewhere classified. Fourteen point nine percent (275/1843) were given an additional diagnosis of chronic daily headache, including medication-overuse headache (MOH, 49.5%), chronic tension-type headache (CTTH, 32.7%) and chronic migraine (CM, 13.5%). The visual analogue scale (VAS) score of TTH with MOH was significantly higher than that of CTTH (6.8±2.0 vs 5.6±2.0, P<0.001). The similar result was also observed in VAS score between migraine with MOH and CM (8.0±1.5 vs 7.0±1.5, P = 0.004). The peak age at onset of TTH for male and female were both in the 3^rd decade of life. However, the age distribution at onset of migraine shows an obvious sex difference, i.e. the 2^nd decade for females and the 1^st decade for males.

Conclusions/Significance

This study revealed the characteristics of the headache clinic outpatients in a tertiary hospital of North China that migraine is the most common diagnosis. Furthermore, most headaches in this patient population can be classified using ICHD-II criteria.     

Diurnal variation of tension-type headache intensity and exacerbation: An investigation using computerized ecological momentary assessment

ABSTRACT: BackgroundsTension-type headache is a common psychosomatic disease. However, diurnal variation of headache is yet to be clarified, perhaps due to the lack of an appropriate method to investigate it. Like other painful diseases, it would be helpful to know if there is diurnal variation in tension-type headaches, both for managing headaches and understanding their pathophysiology. The aim of this study was to determine if there is diurnal variation in the intensity and exacerbation of tension-type headache. METHODS: Patients (N = 31) with tension-type headache recorded for one week their momentary headache intensity several times a day and their acute headache exacerbations using a watch-type computer as an electronic diary (computerized ecological momentary assessment). Multilevel modeling was used to test the effects of time of day on momentary headache intensity and on the occurrence of acute exacerbations. RESULTS: A significant diurnal variation in momentary headache intensity was shown (P = 0.0005), with the weakest headaches in the morning and a peak in the late afternoon. A between-individual difference in the diurnal pattern was suggested. On-demand medication use was associated with a different diurnal pattern (P = 0.025), suggesting that headache intensity decreases earlier in the evening in subjects who used on-demand medication, while headache subtype, prophylactic medication use, and sex were not associated with the difference. The occurrence of acute headache exacerbation also showed a significant diurnal variation, with a peak after noon (P = 0.0015). CONCLUSIONS: Tension-type headache was shown to have a significant diurnal variation. The relation to pathophysiology and psychosocial aspects needs to be further explored.     

Inheritance of chronic tension-type headache investigated by complex segregation analysis

We investigated the mode of inheritance of chronic tension-type headache in 122 families. The probands were from the Copenhagen Headache Clinic, Denmark. The criteria of the International Headache Society were used. The patterns of segregation of chronic tension-type headache were assessed by complex segregation analysis performed with the computer program POINTER. Of the 122 probands with chronic tension-type headache, 56 had 71 first-degree relatives with chronic tension-type headache. The complex segregation analysis indicates that chronic tension-type headache has multifactorial inheritance. Received: 22 April 1997 / Accepted: 4 September 1997     

Change Mechanisms Associated with Combined Relaxation/EMG Biofeedback Training for Chronic Tension Headache

Therapeutic mechanisms hypothesized to underlie improvements in tension headache activity achieved with combined relaxation and eleclromyographic (EMG) biofeedback therapy were examined. These therapeutic mechanisms included (1) changes in EMG activity in frontal and trapezii muscles, (2) changes in central pain modulation as indexed by the duration of the second exteroceptive silent period (ES2), and (3) changes in headache locus of control and self-efficacy. Forty-four young adults with chronic tension-type headaches were assigned either to six sessions of relaxation and EMG biofeedback training (N = 30) or to an assessment only control group (N = 14) that required three assessment sessions. Measures of self-efficacy and locus of control were collected at pre- and posttreatment, and ES2 was evaluated at the beginning and end of the first, third, and lost session. EMG was monitored before, during, and following training trials. Relaxation/EMG biofeedback training effectively reduced headache activity: 51.7% of subjects who received relaxation/biofeedback therapy recorded at least a 50% reduction in headache activity following treatment, while controls failed to improve on any measure. Improvements in headache activity in treated subjects were correlated with increases in self-efficacy induced by biofeedback training but not with changes in EMG activity or in ES2 durations. These results provide additional support for the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies, at least in young adult tension-type headache sufferers.     

A preliminary analysis of EMG variance as an index of change in EMG biofeedback treatment of tension-type headache

The effectiveness of EMG biofeedback training for tension headache has been well established. Previous studies evaluating changes in an average EMG activity score from pre- to posttreatment have not consistently found a relationship between a reduction in average EMG activity and headache improvement at posttreatment. The current study is a preliminary analysis of the utility of EMG variance as another possible mechanism of change. Frontalis EMG average activity and variances from 6 chronic tension-type headache sufferers who demonstrated significant improvement in headache activity at posttreatment (at least 70%) and 6 chronic tension-type headache sufferers who did not demonstrate improvement (less than 30%) were examined across 6 sessions of biofeedback treatment. The improved group demonstrated larger time-specific EMG variance in relation to mean EMG amplitudes during all treatment sessions. A dramatic decline in time-specific variance was observed during the later treatment sessions for improved participants; this pattern was not observed in the group who demonstrated little or no improvement. Results from the current study suggest that the inclusion of both average EMG activity and EMG variance may provide a more comprehensive measure to evaluate possible physiological changes responsible for improvement in headache activity following EMG biofeedback training.     

Chronic tension-type headache in school-aged children--personality traits and behavior

Basic personality traits and specific behavior characteristics were assess in 39 patients (12 to 15 years old) having chronic tension-type headache. Patients were referred for clinical examination to the Neural-pediatrics Ward of the Department of Pediatrics, Osijek, Croatia. Eysenck Personality Questionnaire--Juniors (EPQ-J), a new Croatian personality Questionnaire of domination, aggression, introversion and ambition (DAIA), were applied for the testing. The scores obtained by patients in personality questionnaires were compared with averages scores normal sample of healthy pupil same ages. Our patients were found to have no signs of emotional instability. Their behavior is prosocial, nonaggressive, and ambitious, aimed at the achievement of superior results at school and life although already quite successful in their studies. Tensions arising from the school setting seem to be important factors triggering tension-type headaches.     

Vagotomy; clinical results,with a note on temporary gastrostomy

Often in the treatment of chronic headache, both physical and emotional factors are entailed. Therefore, the results of therapy are limited by the potentialities of the patient in therapy, the pharmacologic actions of the medications used, and the physician's interest and orientation toward the problem. The treatment of choice is generally a combination of psychotherapy and drug therapy. Results in a large series of tests with these types of headaches indicate the effectiveness of treatment is greatly influenced by the patient's psychological reaction to the treatment situation in general and in particular to having received a remedy from the physician. Patients with migraine did not respond to placebos as well as did patients with tension headache, post-traumatic headache and headache associated with hypertension.     

Blood volume pulse biofeedback treatment of chronic cluster headache

Behavioral interventions shown to be clinically effective in the treatment of migraine headache have generally not been employed for cluster headache. Herein, we report on the treatment of a severe case of chronic cluster headache with a common method of migraine treatment, temporal blood volume pulse (BVP) biofeedback. The patient was a 61-year-old male, medically diagnosed as suffering from chronic cluster headaches for over 20 years. Following an 18-day baseline, 14 BVP biofeedback sessions were conducted over a 7-week period. By the last 2 weeks of treatment, there was a 70% reduction in daily headache frequency and a 45% decrease in headache severity. Improvement was maintained at 1, 3, 6, 12, and 21 months follow-up. Large decreases in the consumption of migraine abortives, narcotic analgesics, and antiemetics were also observed. These encouraging results call for further evaluation of the efficacy of BVP biofeedback treatment of chronic cluster headache.This research was supported in part by the Psychological Services Center, Memphis State University. Portions of this article were presented at the meeting of the Society of Behavioral Medicine, Chicago, March 1982.     

Headache and Oral Parafunctional Behaviors

This study tested the hypotheses that individuals with headaches would show significantly more oral parafunctional behaviors than non-headache controls, be diagnosed with one or more temporomandibular disorders (TMD) significantly more frequently than controls, and would report significantly less pain and other symptoms of headache after participating in a habit reversal treatment to reduce oral parafunctional behaviors, compared to a wait list control. In Phase I, individuals with and without self-reported headaches were examined by a blinded examiner and participated in a week-long experience sampling protocol (ESM) to assess oral parafunctional behaviors, pain, and emotional states. In Phase II, those with headaches were randomly assigned to either a habit reversal treatment or to a wait list control group. In the last, sixth week of the program, participants again completed an ESM protocol. Results showed that headache patients were significantly more likely to report oral parafunctional behaviors than non-headache controls and to receive a Research Diagnostic Criteria/TMD diagnosis. Results from Phase II showed general improvement in both groups on pain and parafunctions. Individuals with headaches engage in significantly higher rates and intensities of oral parafunctional behaviors. Treatment of these behaviors using habit reversal techniques appears to have the same effect on pain as waiting.     

Analysis of Trigger Factors in Episodic Migraineurs Using a Smartphone Headache Diary Applications

Background

Various stimuli can trigger migraines in susceptible individuals. We examined migraine trigger factors by using a smartphone headache diary application.

Method

Episodic migraineurs who agreed to participate in our study downloaded smartphone headache diary application, which was designed to capture the details regarding headache trigger factors and characteristics for 3 months. The participants were asked to access the smartphone headache diary application daily and to confirm the presence of a headache and input the types of trigger factors.

Results

Sixty-two participants kept diary entries until the end of the study. The diary data for 4,579 days were analyzed. In this data set, 1,099 headache days (336 migraines, 763 non-migraine headaches) were recorded; of these, 772 headache events had with trigger factors, and 327 events did not have trigger factors. The common trigger factors that were present on headache days included stress, fatigue, sleep deprivation, hormonal changes, and weather changes. The likelihood of a headache trigger was 57.7% for stress, 55.1% for sleep deprivation, 48.5% for fatigue, and 46.5% for any trigger. The headaches with trigger factors were associated with greater pain intensity (p<0.001), headache-related disability (p<0.001), abortive medication use (p = 0.02), and the proportion of migraine (p < 0.001), relative to those without trigger factors. Traveling (odd ratios [OR]: 6.4), hormonal changes (OR: 3.5), noise (OR: 2.8), alcohol (OR: 2.5), overeating (OR: 2.4), and stress (OR:1.8) were significantly associated with migraines compared to non-migraine headaches. The headaches that were associated with hormonal changes or noise were more often migraines, regardless of the preventive medication. The headaches due to stress, overeating, alcohol, and traveling were more often migraines without preventive medication, but it was not evident with preventive medication.

Conclusion

Smartphone headache diary application is an effective tool to assess migraine trigger factors. The headaches with trigger factors had greater severity or migraine features. The type of triggers and the presence of preventive medication influenced the headache characteristics; hence, an investigation of trigger factors would be helpful in understanding migraine occurrences.     

Biofeedback Treatment for Headache Disorders: A Comprehensive Efficacy Review

The aim of the present review was to critically evaluate the documented evidence regarding the efficacy of biofeedback for the two most prevalent headache conditions––migraine and tension-type headache. Drawing upon two recently published meta-analyses, data from 150 outcome studies, including randomized controlled trials as well as uncontrolled quasi-experimental designs, were screened. Of these, 94 studies were selected for inclusion according to predefined criteria. Meta-analytic integrations were carried out separately for the two conditions of interest. The main results were medium-to-large mean effect sizes for biofeedback in adult migraine and tension-type headache patients. Treatment effects remained stable over an average follow-up period of 14 months, both in completer and intention-to-treat analyses. Headache frequency was the primary outcome variable and showed the largest improvements. Further significant effects were shown for perceived self-efficacy, symptoms of anxiety and depression, and medication consumption. Reduced muscle tension in pain related areas was observed in electromyographic feedback for tension-type headache. Biofeedback was more effective than waiting list and headache monitoring conditions in all cases, while electromyographic feedback for tension-type headache showed additional significant effects over placebo and relaxation therapies. Levels of efficacy (migraine: efficacious, level 4; tension-type headache: efficacious and specific, level 5) and recommendations for future research are provided.

HEADACHE—Pharmacological Approach to Treatment

The great majority of headaches a physician treats in office practice can be divided into two main categories, muscular contraction headache of tension type and vascular headaches of the migraine type.The most satisfactory symptomatic therapy for tension headache is by the use of a nonnarcotic analgesic agent combined with a tranquilizer or sedative. On the other hand, symptomatic relief of migraine is best obtained by the use of a suppository of ergotamine tartrate and caffeine combined with an antiemetic or antispasmodic.Interval treatment of patients with tension and migraine headache centers on helping the patient understand his emotional problems. Prophylactic drug therapy for patients with tension headache includes the limited use of tranquilizers and sedatives. Recently, striking benefits in some patients with migraine have been achieved by the prophylactic use of the antiserotonin drug methysergide (UML 491).