Behavioral Treatments of
Migraine Headaches
g
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,
2007)
• 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 ofheadache
• 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)
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
Biofeedback
• 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
Headaches
• 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
Behavioral
• 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
2005)
• 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
Interventions
• American Academy of Family Physicians • American Academy of
Neurology
• Canadian Headache Society
• National Institutes of Neurology
• American Headache Society
• American College of Physicians • American Medical
Association
Health
• National Headache Foundation • World Health
Organization
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
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
Insomnia
• Problems going and / or staying asleep • Addresses sleep onset and sleep
maintenance maintenance
• Can exacerbate headaches
Insomnia
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 patientswith 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
Conclusion
• Behavioral treatments of headaches are a viable treatment
• Sleep disturbance exacerbates headaches • Treating the sleep disturbance often reduces
headaches
• Behavioral treatments of insomnia more effective than medication and can reduce headache severity