BEHAVIORAL MIGRAINE MANAGEMENT

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BEHAVIORAL MIGRAINE MANAGEMENT

• Kenneth A. Holroyd, Ph.D.
• Ohio University

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Behavioral Treatments

• Relaxation Therapy
• Biofeedback Therapy
• Cognitive-Behavior (Stress-Management) Therapies
• Combinations of the above treatments

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Relaxation Training

• Types of Relaxation Training
• Progressive muscle relaxation
• Autogenic training
• Meditation or passive relaxation

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...Im telling you, Ed. Youve got to learn to
deal with tension better
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Relaxation Training

• Relaxation training involves a specific set of
  procedures not just trying to relax
• Individuals adapt to chronic muscle tension
• May not recognize tension or relaxation
• May not know how to relax
• Progressive muscle relaxation procedure
• Begins with tensing relaxing 12 muscle groups
  (25 min)
• Proceeds in steps to quick cue controlled
  relaxation that can be used throughout the day
• Goals of relaxation training include
• Increase awareness of early signs of headache
  onset
• Use relaxation to prevent and abort headaches
• Increase personal sense of control (self-efficacy)

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Biofeedback Training

• Monitor headache-related physiological responses
• Present information (feedback) about
  physiological response (e.g., audio tone)
• Patient uses feedback to learn to regulate the
  response

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Biofeedback Training
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Types of Biofeedback Training

• Electromyographic (EMG) Biofeedback
• Typically for tension-type headache
• Thermal (hand-warming) biofeedback
• Typically for migraine
• Other
• Cephalic vasomotor biofeedback
• GSR feedback, Neurofeedback (EEG)

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Biofeedback Training

• EMG Biofeedback
• May be effective in in individuals who are unable
  to master relaxation training
• May enable deeper muscle relaxation than
  relaxation training
• May be accepted by patients who are averse to
  psychological treatment
• Thermal Biofeedback
• Hand-warming may require weeks of practice to
  learn
• Hand-warming response is used primarily to
  prevent, but also to abort migraines

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Cognitive-Behavioral Stress-Management Therapy

• Teach patients to
• Identify manage stress-generating thoughts
  beliefs
• Prevent stress-related headaches
• Manage pain, distress disability when
  headaches occur.
• Manage psychological consequences (e.g.,
  depression, helplessness) of headaches

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Cognitive-Behavioral Stress-Management Therapy

• Thought Monitoring
• Identify stress-generating thoughts
  underlying beliefs
• Skills training
• Teach cognitive (e.g., self-talk) and behavioral
  (e.g., ) coping skills
• Application
• Apply skills in progressively more challenging
  situations.

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Cognitive-Behavioral Stress-Management Therapy

• Stress-Generating Thoughts
• Catastrophizing
• I wonder whether something serious may happen
• I keep thinking how much it hurts
• Stress- Generating Beliefs
• Expecting Perfectionism
• Expecting Approval

Holroyd et al., 2005
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Cognitive-Behavioral Stress-Management Therapy

• Stress-Generating Thoughts
• Recognizing challenging thoughts
• Coping Self-Talk
• Stress-Generating Beliefs
• Reversing Positions
• Reframing
• Reality Testing

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Management of Migraine in Primary Care
SettingsEvidence-Based Treatment Guideline

• American Academy of Family Physicians
• American Academy of Neurology
• American Headache Society
• American College of Emergency Physicians
• American College of Physicians
• American Osteopathic Association
• National Headache Foundation

U.S. Headache Treatment Guideline
Consortium Member Organizations

• Diagnostic and Neuroimaging
• Acute Treatment
• Preventive Treatment
• Behavioral and Physical Treatment

Guideline Components
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Literature on Behavioral Treatments

• 355 articles identified
• 70 controlled trials identified
• 39 prospective, randomized, controlled trials
  aimed at prevention of migraine attacks met all
  data extraction requirements

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Statistical Analysis

• Effect Size (each treatment comparison)
  standardized difference between group means
• Percentage Improvement
  pre-tx - post-tx/pre-tx score X 100
• Summary Statistics
• summary ES using random effects model
• avg. improvement weighted by sample size

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Meta-Analysis of Behavioral vs. Pharmacologic
Treatment of Migraine ( change)
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Specific Treatment Recommendations

• Findings
• RLX, BF, and CBT are all somewhat effective in
  preventing migraine when compared with controls.

• Recommendation
• RLX, BF, and CBT may be considered as treatment
  options for prevention of migraine (Grade A
  Evidence)

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Specific Treatment Recommendations

• Findings
• Behavioral treatments have been directly
  compared and combined with drug treatments for
  migraine. Propranolol conferred additional
  benefits when added BF, and CBT.

• Recommendation
• Behavioral therapy may be combined with
  preventive drug therapy to achieve additional
  clinical improvement
• (Grade B Evidence)

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Meta-analysis of Pediatric Migraine Treatments
Herman, Kim Blanchard, 1995
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Pediatric Migraine

• Readily learn control of physiological response
• High response rate to behavioral interventions
• Game-like task involves child
• Skills can be used into adulthood
• Limited drug options

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Telephone Administered Behavioral Treatment

• Exhibit Headache Management Skills in Clinic
• 100 1 skill
• 67 2 skills
• 27 3 skills
• Relaxation, partial relaxation, diaphragmatic
  breathing, thermal biofeedback

McGrath et al. (1992)
Corrtell et al., in preparation
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Behavioral Migraine Management

• Overview
• Basic Migraine Management Skills
• Relaxation Skills
• Identifying Managing Migraine Triggers
• Recognizing Responding to early Warning Signs
• Effectively Using Evaluating Migraine
  Medications
• Coping with Migraines

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Behavioral Migraine Management

• Advanced Migraine Management Skills
• A. Hand-warming
• Learning hand-warming
• Applying hand-warming to prevent migraines
• or
• B. Stress Management
• Identifying challenging stress- generating
  thoughts
• Identifying challenging stress-generating
  beliefs
• Applying stress-management skills
• 
  

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Headache Locus of Control

• Health Professionals Scale
• Only my doctor can give me ways to prevent
  headaches
• If I dont have the right medication, my
  headaches will be a problem
• My headaches can be less severe if medical
  professionals take proper care of me

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Headache Locus of Control

• Internal Locus of Control
• I can prevent some of my headaches by avoiding
  certain stressful situations
• My headaches are sometimes worse because I am
  overactive
• If I can remember to relax I can avoid some of my
  headaches

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Self-Efficacy Beliefs

• Self-Efficacy Confidence that one can perform
  headache management activities
• Self-efficacy
• Is assessed for a specific domain
• Is assessed with reference to specific behaviors
• Is highly malleable

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Headache Self-Efficacy Scale

• Headache Prevention
• I can prevent some of my headaches by recognizing
  headache triggers
• Disability Management
• I can can keep a mild headache from disrupting
  my day by changing the way I respond to pain

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TCTH TRIAL INITIAL TREATMENT PHASE

• AM Clinical Management
• Placebo Clinical Management
• SMT Placebo
• Baseline
  
  Reevaluation
• SMT
  AM
• 4 weeks
  12 weeks
  4 weeks

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SAMPLE CHARACTERISTICS (N 203)

• Diagnosis All patients IHS 2. 2 CTH
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  co-morbid migraine diagnosis
  IHS 8.2 excluded
• Gender 77 female
• Age M 37.0 years
• Race 95 Caucasian
• Frequency M 26.0 headache days/ month
• Chronicity M 12.5 years problem headaches

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Conclusions

• Behavioral Migraine Management (BMM)
• Combines behavioral interventions in an
  integrated treatment package
• BMM can improve migraines and quality of life
• BMM can help empower patients to be actively
  involved in the management of their migraines
• BMM is a promising intervention for the
  management of migraines in adolescents
• Telephone administration may make BMM more
  accessible to adolescents