Behavioural tendencies are associated with headaches. Let’s paint a common picture seen among headache patients.
Yulia has bad headaches. The question should be when does she not have a headache. She has stressful job, many other obligations, and not enough time for herself. She has a history of depression and sleep issues. She has been using more and more over-the-counter (OTC) medications (i.e., Tylenol and Advil) to try to prevent the headaches, using them every day. She uses caffeine to get her going in the morning and she uses marijuana and “a drink or two of wine” to help relax at the end of the day. To add to it all, her and her boyfriend are having problems and she’s not happy with the way she’s living her life.
When you ask her about if she’s keeping her exercise program, she offers many reasons why she hasn’t:
“I don’t have enough time. If I exercise in the morning, I’ll be late for work and it will make me nervous. And I’m too tired to exercise when I get home. I have so many headaches that I’m missing work and falling really behind. I don’t want to lose out on that promotion.”
When you ask her why she is taking many OTC medications, she says:
“I get afraid the stiffness and ‘off’ feeling I get in the morning will lead to a migraine.”
When you ask her if she has been keeping a regular sleep schedule, she says:
“I stay out late many weekends at then I’m exhausted the next day so I have to sleep in and take a nap. I’ve never been a good sleeper.”
Do you see a problem with this story?
Yulia doesn’t see things in this light. She sees things in the context of the “traditional biomedical model” where she has inflammation in nerve tissue that is causing ALL her symptoms.
She needs to learn and appreciate the biopsychosocial model. This model says that the physiological process that leads to a headache can be triggered if a certain threshold point is met. The threshold is dependent on the patient’s:
Physiological status, for example, the state of the nervous system and genetic susceptibility;
Environmental factors like stress, certain foods, alcohol, hormonal fluctuations, etc.;
Psychological factors like the ability to cope with these factors, both cognitively and behaviourally; and
Social factors like the consequences of the patient having a headache. For example, if the headache causes a day off from work and Yulia really wants that promotion because she needs the extra money because her boyfriend and her are having financial problems and are talking about separating over it, the headache will seem a lot more painful. There is a good schematic picture of this threshold principle in the article on Headache and Wellness.
Schwartz, MS, Andrasik, F. Biofeedback: A Practitioner’s Guide. The Guilford Press (2016).
Were you aware that the following factors will increase the risk of making headaches more chronic:
Davis RE, SmithermanTA, and Baskin SM. Personality traits, personality disorders, and migraine: a review. NeurolSci. 2013;34(Suppl1):S7-S10; LeichsenringF, et al. Borderline Personality Disorder. Lancet2011;377:74-84; Lake A, et al. Headache2009
Mood disorders, Anxiety disorders, Personality disorder like borderline personality disorder (Davis et al., 2013) may cause these patients to be:
Baskin SM. and Smitherman TA. Neurol Sci. 2009;30:S61-S65; Blanchard et al., 1985; Guidettiet al., 1998; Holroyd et al., 1988; Radat et al., Cephalalgia. 2005;25:519-522; Lanteri-Minetet al., 2005; Bigal ME, Lipton RB 2006; Micieliet al., 1985; Monginiet al., 2003; Waldie& Poulton, 2002; Scher, et al 2008
Medical risk factors
Scher, et al 1998, 2003,2004; Bigal & Lipton, 2006; Katsarava, et al, 2004; TietjenGE, et al. Neurology. 2007;69(10):959-968; Tietjan, GE, et al. Headache. 2017 Jan;57(1):45-5
We discussed many of these in our article on Headache and Wellness. To review:
Follow as many of the tenets of of CBT-i as you can. Certain objective parts that have been found to improve headaches are:
Smitherman, et al 2016; Calhoun & Ford, 2007
Exercise: Increase aerobic exercise.