HEADACHE AND BEHAVIOURAL TREATMENT

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:

 

Stress

 

    • High levels of daily stress. Interestingly many of migraine patients will get migraines after a flurry of stress, during the “let-down”.
    • History of trauma
      History of childhood mistreatment
    • History of depression or psychological issues may cause stress to have more of an effect
    • Many headache patients don’t have the coping skills to manage stress and chronic headache,

 

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

 

Psychological factors

 

Mood disorders, Anxiety disorders, Personality disorder like borderline personality disorder (Davis et al., 2013) may cause these patients to be:

 

  1. 3 times less likely to comply with treatment regimens (anxiety or mood disorder patients).
  2. Less likely to tolerate drugs. We see this very commonly in our patients which is why we put a lot of effort in strengthening the quality of “natural” or nonpharmacological treatments and peripheral nerve blocks.
  3. Less likely to respond positively to drug and behavioural therapy.
  4. Increased risk of headache relapse.

 

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

 

  1. Obesity
  2. Sleep apnea
  3. Caffeine overuse
  4. Medication overuse. This is where commonly used medications for headache may cause headaches if used too frequently (Medication Overuse Headaches [MOH]). Different medications have different thresholds for triggering MOH. It looks like this might be at play for Yulia in the story above. There are some other criteria for MOH:
    • headache has to be present for 15 days a month or more.
    • regular overuse of headaches for a period of time exceeding 3 months, with a frequency of:
    • 10 or more days of the month for ergotamine, triptans, opioids or combination analgesics involving one of these. Medications like Fiorinal can lead to MOH with as little as 5 days of use/month.
    • 15 or more days of the month for simple analgesics (e.g., Tylenol, advil, etc.).
    • Headache develops or becomes markedly worse during the period of medication overuse.

 

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

A shift in perspective is the first most empowering step in mitigating the effect of headache on your lifestyle. We need to change the locus of control; we need to shift from external factors having their way with patients to (patients’) internal factors setting the tone. The focus has to shift from being on illness to being on wellness. Common Reactions to “External” factors
  • Helplessness – “fix me”
  • Fatalistic/blamer – “it’s killing me…”, “I’ll never…”, “I can’t not because of me, but…”, etc.
  • Complaining of the symptoms without a plan of action to help the situation
  • Looking for that “magic treatment”
  • Excuses – “Yes…but”
  Common “Internal (patient)” factors that facilitate success  
  • Take it one thing at a time
  • Take responsibility for your treatment
  • Be a good historian. Jot down your observations on your headaches and be frank with yourself.
  • Have a plan. Focus on what you can do rather than what is being done to you. Focus on wellness rather than illness.
  • Sets realistic goals
Martin, Holroyd, Penzien. The headache-specific locus of control scale.Headache, 1990
  • Some prefer not to use medication.
  • Some have reasons for which they can’t take medication.
  • Some don’t have benefit effect with medication.
  • To avoid Medication-Overuse Headache (MOH), see below.
  • Some of stress in their lives, psychological issues and stress-coping issues which they want to address. Some are pregnant, planning to become pregnant or nursing and want to avoid medication.
  • Silberstein et al., U.S. Headache Consortium, 2000

    We discussed many of these in our article on Headache and Wellness. To review:

     

    1. Diet:

     

    • Caffeine: Reduce or eliminate caffeine. If you can’t eliminate it then aim to keep your caffeine
    • consistent. That is, try to have it at the same time every day and the same amount. Aim for less than 200 mg/day of caffeine.
      Eat nutritious meals at regular intervals.

     

    2. Sleep:

     

    Follow as many of the tenets of of CBT-i as you can. Certain objective parts that have been found to improve headaches are:

    • Adopt a routine/consistent bedtime.
    • Eliminate all non-sleep related activities in the bedroom other than intimacy: no watching TV, reading, or listening to music in bed.
    • Employ relaxation strategies to help you get to bed faster.
    • Cut out daytime naps.
    • Get out of bed if can’t sleep and go in different room.
    • Consistent time of evening meal a minimum of 4 hours before bedtime & limit fluid intake within 2 hours of bedtime.
    • No exercise during night-time.

     

    Smitherman, et al 2016; Calhoun & Ford, 2007

     

    Exercise: Increase aerobic exercise.

    To maximize your compliance with your treatment, follow some of the follow principles:
    • Keep your follow-up appointments with your MD
    • Simplify your headache regimen
    • Keep an activity journal to help track that you are keeping a balanced lifestyle. This means that you have to have time-limits for activities and utilize the 4 P’s.
    • Make time for relaxation. Reduces muscle tension and autonomic arousal. It is usually delivered along with biofeedback or CBT.
    • Aim to involve biofeedback in your life. HRV training, thermal and sEMG have all been proven to be helpful in headache management.
    • Keep a headache journal up-to-date.
    • Get support from loved ones and family to help keep your lifestyle balanced.
    • History is the best teacher. Learn what works and what doesn’t work for you.
    • Get educated about your condition and the treatments. This helps with provide realistic expectations and strengthens copings skills.
    • Don’t ignore emotional problems (Also, listen to Podcast Concussion 101, Episode 5: The glass is half full; and Episode 6: Down but not out). Make stress management a priority. Psychotherapy is helpful here.
    Rains et al. Headache2006;46:1395-1403; Baskin, Neurol Sci 2007;28:S1-S5
    Although it is nearly impossible to prove that a trigger directly caused a headache, one can correlate triggers if they always are hanging around at the time of a headache. The most common triggers are:   1. Stress (80%). High-density minor daily (chronic stressors) are thought to be more offensive than major stressors (Holm et al., 1986). Stress-triggered headaches are often experienced during the “let-down” phase, when the patient finally unwinds after the flurry of stress. It is also referred to as the “weekend headache”. Other factors that dictate how offensive stressors are include:  
  • Seeing these stressors in a negative light.
  • Having very emotional responses to these stressors.
  • Wanting stress management skills/behaviours.
  • Personality features (i.e., perfectionism, socially fearful, etc.)
  •   2. Hormonal issues in women (65%)   3. Irregular meal schedule (57%)   4. Environmental factors (53%, e.g., barometric pressure changes, temperature changes [30%])   5. Sleep disturbances (50%)   6. Environmental irritants (e.g., noise, odours [44%], allergens, smoke [36%], etc.)   7. Neck issues ([38%] see podcast Concussion 101, Episode 7: What the heck, neck?! )   8. Visual factors (lights [37%], see binocular vision article)   9. Specific foods and drinks (27%) – most recognized agents are sulphites, nitrites, MSG, alcohol [38%].   10. Activities like excessive/too little exercise (22%) or car travel.   11. sexual activity (5%) Triggers are often “time-lagged”, with headaches occurring several hours or days after exposure to the trigger   Kelman, L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27(5):394.
    Grade A (32-49% reduction in headache index) psychotherapy techniques for headache consist of:  
  • Cognitive Behavioural Therapy (CBT);
  • Biofeedback (sEMG and thermal); and
  • Relaxation training. Silberstein et al., U.S. Headache Consortium, 2000
  •   CBT is a big topic but, in a nutshell, for headache patients, it involves:  
  • Opportunities to examine negative predictions and danger cognitions.
  • Rehearse adaptive cognitive and behavioral responses to the development of a migraine.
  • Develop action plans and increase self-efficacy.
  • Teach Coping Skills and Mindfulness to Modify Distress.
  •   Patients’ perceptions of stressful situations contribute to the persistence/worsening of headaches. The automatic thoughts stemming from these perceptions probably mediate a neurological reactivity. That is, the patient may feel victimized because of a lack of control over the headaches and also feel chronic muscular tension and arousal of the sympathetic nervous system (fight-or-flight system) due to the situation (Appelbaum et al, 1990). To build on this, patients’ perceptions of successful experiences at regulating headaches in and of itself will cause a reduction in headaches (Holroyd et al., 1984; Gauthier et al., 1994). This basically saying that mind over matter has validity. In many ways, the use of biofeedback just increases patients’ confidence and feeling of self-efficacy; that is, the technology doesn’t teach the relaxation or coping skills, it’s just a mirror to what the patient is doing!   Coping skills for headache patients stem from education and involves:  
  • Preparing for a migraine
  • Executing an action plan for the beginning of the migraine (medical, behavior, autonomic regulation, mood)
  • Stay calm and use back-up methods if the pain increases
  • Coping with thoughts and feelings at critical moments
  • Self-reflection and evaluation without criticism and judgement
  •   Behavioural Therapy is a Grade B technique and involves:   things like educating the patient about behavioural changes that can support wellness in this context (i.e., headache). In the example above, it is obvious that Yulia’s headaches are getting worse and she is using many simple analgesics with no effect. We will have to educate her to change her behaviour rather than use more Tylenol.   What about other approaches?   ♦ More research is needed to identify/recognize other useful techniques. Many patients find mindfulness approaches helpful. Mindfulness has been added to CBT to lead to Acceptance and Commitment Therapy (ACT); it has also been added to biofeedback. ♦ Most psychotherapists categorize their approaches as eclectic: they draw on many techniques from a variety of different types of therapy, including dynamic, cognitive, and behavioral approaches. As depression seems to be common in chronic headache sufferers, the goals of psychological therapy is often to check this through:  
  • Increasing activity and exercise level
  • Increasing pleasurable and rewarding behaviors
  • Enhancing social relations/interpersonal skills
  • Improving self-esteem & self-reward and decrease self-criticism
  • Developing problem solving strategies
  • Countering distorted automatic thinking
  •   Leahy, Holland & McGinn, 2012; Beck, 1996; Markowitz & Weissman, 1995
    In Yulia’s case, behavioural therapy outlining the strategies above are called for: • CBT-i; regular cardiovascular exercise; energy and stress management strategies including relaxation and therapeutic activities; dietary changes – reduced alcohol, caffeine and regular nutritious meals; and possibly more. • Some psychotherapy may be involved too if her anxiety is a possible cause for being quick to reach for medication when she doesn’t have a headache but has a sense that something is brewing…every day; this will contribute to MOH. This may also serve as a flywheel to unraveling inaccurate automatic or fundamental thoughts (or assumptions) she is having: feeling better involves taking a pill; and that medical care comes into play only when there is illness rather than healthcare is there to promote wellness. • Excess consumption of medication is often motivated by anticipation and fear of future attacks (hence the tendency to self-administer acute medications as prophylaxis (Peres et al., 2007). Along this line, this may lead to identifying other (negative and unwarranted) beliefs she has about herself that is contributing to her negative experience of life (i.e., it may not all be because of the headaches). In fact, migraine does increase the risk of depression but depression also increases the risk of migraine (Schwartz, M, Andrasik, F, 2016)). Patients who take excessive amounts of medication are also more likely to experience psychiatric conditions, most commonly depression and anxiety (Radat et al., 2005). • To help her deal with the withdrawal symptoms of MOH, the medical team can institute more effective acute therapy and (better) prophylactic therapy – a medication that is not only used during acute attacks (injected or oral) that helps reduce the burden of the headaches; they will educate her about how to appropriately manage her headaches with medication. Sometimes peripheral nerve blocks are useful to mitigate the withdrawal headache that occurs with stopping these over-used medications. Campbell, Penzien& Wall (2000) Evidence-based guidelines for migraine headaches: Behavioral and physical treatments. AAN Website