Headache Types. Behavioral Treatments of. Tension Headache. Migraine Headache. Mixed Headaches. TMJ Disorder. Tension Migraine.

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Behavioral Treatments of

Migraine Headaches


Jonathan D. Cole, Ph.D. Clinical and Health Psychologist

Bluegrass Health Psychology Lexington, KY

Headache Types

• Tension • Migraine • Mixed • Mixed • Cluster • TMJ

Tension Headache

• Occurs outside the skull

• Muscles outside the skull contract and pinch nerves between the muscle and skull nerves between the muscle and skull • Long term muscle contraction produce

lactic acid

• Very sensitive to stress

Migraine Headache

• A vascular headache

• An inflammation of blood vessels inside and outside the brain

• Often a throbbing pain • Is hereditary

• Light and sound sensitivity • Unsure the true cause

Mixed Headaches

• Combination of Tension and Migraine Headaches

TMJ Disorder

• Pressure from on the TMJ • Can be from teeth grinding

• Can trigger a migraine or tension headache • Can trigger a migraine or tension headache • Stress related


Migraine Triggers (Kelman,


• Stress (79.7%)

• Hormones in women (65.1%) • Not eating (57.3%)g ( )

• Weather (53.2%) • Sleep Disturbance (49.8%) • Odors (43.7%)

• Neck Pain (38.4%) • Light (38.1%)

Migraine Triggers (Continued)

• Alcohol (37.8%) • Smoke (35.7%) • Sleeping Late (32 %) • Sleeping Late (32 %) • Heat (30.3%) • Food (26.9%) • Exercise (22.1%) • Sexual Activity (5.2%)

Headache Medication

• Vaso-Constrictors • Muscle Relaxers • Narcotic Medication • Narcotic Medication

• Over the Counter Medication • Anti-Seizure Medications

Rebound Headaches

• Taking daily doses of narcotic, aspirin, Tylenol, or barbituates

• Makes headaches worse and more frequentMakes headaches worse and more frequent • Majority of chronic daily headaches are a

result of rebound headaches

Psychological Headache Assessment

• Frequency, intensity, location, and type of


• Any recent change in symptomsAny recent change in symptoms • Neurological evaluation?

• Relationship with headache and stress • Other medical conditions (IBS, Seizure

Headache Assessment (Cont)

• Headache medications • Aspartame/MSG use

• Alcohol/ Drug useg

• Sleep Assessment (Insomnia, Apnea, ect) • Stress

• Psychiatric status (depression, anxiety, PTSD, ect.)


Things you can do for Headaches

• Avoid Aspartame/ NutraSweet • Limit Alcohol

• Improve sleep • Improve sleep

• No daily pain medication • Watch diet

• Behavioral headache treatment

Behavioral Headache Treatment

• Relaxation Training • Biofeedback

• Cognitive Behavioral Therapy • Cognitive-Behavioral Therapy

Autonomic Nervous System

Sympathetic Nervous System

Parasympathetic Nervous System

Fight or Flight Muscle Tension

GI Irritation Decrease Peripheral Blood Flow Heart Rate and Body Temperature Increase

Decrease Muscle Tension Calms GI Tract Increase in Peripheral Blood Flow Heart Rate and Body Temperature Decrease

Relaxation Training

• Teach how to activate parasympathetic nervous system

• Include hand warming imagery if migraineInclude hand warming imagery if migraine • Better if taught in person

• Encourage practicing

• Perform right when headache comes on for best results

Types of Relaxation

• Progressive muscle relaxation

• Autogenic relaxation – passive PMR (no tensing)


• Stretch relaxation • Imagery

Imagery relaxation

• Use all senses, smell first, touch, sound, then sight

• For hand warming try lying on the beachFor hand warming try lying on the beach with hands and feet in warm sand or warming hands and feet in front of a fire in a cabin in the woods



• Works best if used in conjunction with relaxation

• EMG measures surface tension to trainEMG measures surface tension to train muscle relaxation, reducing tension • Thermal teaches to increase hand

temperature, increasing blood flow to periphery, reducing tension from migraine

EMG Biofeedback Sites for


• Frontalis – forehead (horizontal) • Cervical paraspinal – neck (vertical) • FnP (Schwartz technique) one forehead • FnP (Schwartz technique) – one forehead

and one cervical paraspinal lead on the same side (for occipital headaches) • Masseter - Jaw (Vertical)

• Trapezius – tops of shoulder (vertical)

Thermal biofeedback

• Can use a finger tip thermometer before and after relaxation with hand warming

• Use same finger for post test that was usedUse same finger for post test that was used for the pre-test

• Try to get temperature to 90 degrees F or above


• Relaxation – autonomic self regulation • Increase pleasurable activities

• Decrease avoidance behaviors • Decrease avoidance behaviors • Reward positive behaviors

• Develop new stress and anger management strategies

Case Example

• 13 year old female with daily headache, with intermittent severe pain

• Taught relaxation training with handTaught relaxation training with hand warming

• Performed thermal biofeedback

• Provided cognitive therapy to reduce stress

Case Example

• Patient increased her hand temperature by 15 degrees

• Patient eliminated severe headachesPatient eliminated severe headaches • Patient reduced severity of daily headaches


Behavioral Headache Treatment

Outcomes (Rains, Penzien, et al


• Meta-analysis indicated behavioral

interventions consistently yield 35% to 55% improvement in migraine and tension p g headaches

• Effective with pediatric headache

• Can be used in conjunction with medication

Organizations Endorsing

Behavioral Headache


• American Academy of Family Physicians • American Academy of


• Canadian Headache Society

• National Institutes of Neurology

• American Headache Society

• American College of Physicians • American Medical



• National Headache Foundation • World Health


Why is this not used?

• Biofeedback reimbursement – only until recently have new codes been available • Limited number of trained psychologistLimited number of trained psychologist • Patient resistance to seeing a “shrink”/ it’s

in my head but it’s not in my head

Sleep Disorders Affecting Headache

• Sleep Apnea

• Restless Leg Syndrome/ Periodic Limb Movement


• Bruxing/ Night time teeth grinding • Insomnia

PAP Desensitization

• Training patients to tolerate the CPAP mask • Takes an average of 3 sessions with 92%

success success

• Teaches how to relax while wearing the mask

Bruxing/ Night time Teeth Grinding

• When person grinds or clenches teeth when asleep • Can bite down 10-20 times harder when asleep

• Can put pressure on the TMJ causing painp p g p

• Can trigger a headache • Can damage teeth • Stress makes this worse • Bite Guard treats this • CBT helps



• Problems going and / or staying asleep • Addresses sleep onset and sleep

maintenance maintenance

• Can exacerbate headaches


Threshold---Indirect Target for CBT Treatment

Direct Target for CBT Treatment

How Insomnia Becomes Chronic: The 4-Factor Model

Pre- mo rb id A cut e Early C hro nic Sho rt T erm Lo ng T erm

Predisposing Precipitating Perpetuating Conditioned Arousal

CBT Treatment of Insomnia

• Address irrational beliefs about sleep • Improve sleep hygiene

• Sleep restriction (should not be done for • Sleep restriction (should not be done for

seizure or bipolar disorders) • Improve sleep efficiency • Eliminate sleep medication

(benzodiazepines, Ambien, ect.)

CBT with Insomnia Outcomes

• Found more effective than Ambien short and long term

• Found more effective than Lunesta short and long term

CBT Insomnia Treatment for

Headaches (Calhoun, 2007)

• Behavioral sleep treatment given to patients

with transformed (chronic daily) migraine • 48% of the patients reverted back to48% of the patients reverted back to

episodic migraines with just treating the sleep component

Case Example

• 29 year old female with recurrent migraines and primary insomnia

• Taught relaxation and hand warmingTaught relaxation and hand warming • Taught basics of sleep and sleep hygiene • Addressed irrational thoughts regarding


Case Example

• 4 week follow up patient has had no migraine episodes

• Patient is sleeping through the night and hasPatient is sleeping through the night and has increased sleep to 7 hours

• Sleep efficiency increased from 60% to 95%

Case Example

• 50 year old male with daily migraine headaches and sleep apnea

• Was having difficulty tolerating his CPAP • Was taking in large amounts of diet soda per day • Taught CPAP Desensitization

• Taught relaxation and hand warming imagery • Had him stop his Aspartame use

Case Example

• 6 week follow up found no daily migraine with one migraine in the past 4 weeks • Patient was tolerating his CPAP for 7 hoursPatient was tolerating his CPAP for 7 hours

per night

• Was feeling well rested the next day

Why has this not been used

• Limited psychologists trained • Not a quick fix

• Pharmaceutical companies have larger • Pharmaceutical companies have larger

advertising budget


• Behavioral treatments of headaches are a viable treatment

• Sleep disturbance exacerbates headaches • Treating the sleep disturbance often reduces


• Behavioral treatments of insomnia more effective than medication and can reduce headache severity