Introduction
Headache patients arrive to the doctor with a variety of concerns in addition to their head pain. Effective diagnosis and management of headache may only occur after a careful assessment of the specific needs of the individual patient. It is essential that the clinician remember that we are treating people and not merely pain. This is especially important when treating individuals with complex headache problems and/or children with headache. In the present medical environment of managed care, clinicians are often put in a position of conducting time-limited interviews and examinations that make such a comprehensive assessment and treatment difficult.
Headache patients bring with them a history of experiences and expectations with respect to medical care and other treatments. Some feel like "medical orphans" after being abandoned by clinicians who felt that the headaches must have been due to psychiatric issues since the patient did not respond to the first few treatments that were attempted. Many patients are looking primarily for pain relief although some want reassurance that their head pain is not a sign of some underlying, dangerous organic problem. Some are on a quest for a magic pill. All, however, need to know that the clinician takes their symptoms seriously and views headache as a valid medical disorder.
Behavioral Medicine Program for Headache Treatment
The following is a behavioral medicine program for treating headache patients. It is an important component to good pharmacological care in the management of a patient’s headache problem. The treatment plan has several goals:
Education: Informing the patient about current concepts of regarding causes and treatment of headache Dietary and behavioral factors: Altering lifestyle factors that may contribute to or perpetuate headache Self-regulation/biofeedback: Providing instruction in ways to control physiological responses thought to be involved in headache Cognitive/behavior modification: Adjusting actions, attitudes, and expectations that can lead to physiological arousal and headache
Participation: Involving the patient as an active participant in the treatment process
Education
A basic understanding of headache mechanisms is the foundation on which the patient’s participation in the treatment process is built. Genetic predispositions with respect to migraine, the physiology of stress and how it may relate to headache patterns, and the rationale for selecting abortive or preventive agents are important areas for discussion. Drug classes, therapeutic actions, and possible side effects should be explained as they relate to the individual treatment regimen. Compliance is enhanced by detailing the anticipated course of treatment, which may include withdrawal from previous medications and the expected time lag before the benefit of the new medication regimen may be fully realized.
The patient is urged to keep a headache calendar and to bring it to each follow-up visit. In addition to promoting medication compliance, the calendar can provide the clinician with essential information regarding the patient’s headache pattern, response to treatment, and an assessment of the presence of analgesic, ergotamine, or triptan rebound headache. Rebound headaches typically present as mild to moderate to severe pain which waxes and wanes throughout the day, in part, in response to the effects of abortive medications (analgesics, ergotamines, triptans). Pain lasts anywhere from four hours to 24 hours each day. Typically, pain is not throbbing in character, but may assume a throbbing quality secondary to bending or exertion. Pain is usually generalized throughout the head, although there may be specific areas of increased pain. Few patients report associated symptoms of migraine (nausea, vomiting, or sensitivity to light or sound), but most note sleep difficulties (either falling asleep or staying asleep), irritability or depression, and difficulties concentrating.
Dietary and Behavioral Factors
For patients with migraine, an elimination diet may be helpful in the identification of specific foods that serve as triggers for attacks. The patient is asked to go on such a diet for one month and to note any change in the frequency of the migraine attacks. Patients are urged not to miss meals and to eat healthy foods. Most patients benefit from limiting their intake of caffeine to the equivalent of less than two cups of coffee each day.
Medication changes
If previous medications must be stopped (due to rebound headaches), a reduction schedule (recorded on the headache calendar) is helpful. A great deal of support and education may be required during this time as patients often feel as though they are left without enough medication to control the headaches. The clinician must be sensitive to this apprehension on the patient’s part and provide support during this medication transition. A complete discussion of the phenomenon of "rebound headache" is necessary to maximize compliance.
Sleep patterns
Analysis of a person’s sleep pattern is also important. Disturbance in sleep is often a contributing factor to headache. Patients are advised to get enough sleep but to avoid over-sleeping. They are urged to keep consistent sleep hours each night (including weekends). Disturbance in sleep (either falling asleep or staying asleep) may require behavioral or pharmacological intervention. Behavioral interventions could include eliminating afternoon or evening caffeine, learning relaxation strategies to facilitate sleep, and/or engaging in quiet behavior (reading, relaxing in a quiet room with candlelight, taking a warm bath or shower, etc.) in order to prepare the body to sleep.
Self-Regulation/Biofeedback
Biofeedback training is an important option for patients with chronic, refractory headache, which is a headache that doesn’t respond to medications or is very difficult to treat. Biofeedback involves the use of instrumentation that "feeds back" physiological responses to the patient. The feedback provides objective data allowing the individual to be sure that, in fact, he/she is truly learning more adaptive responses to decrease or avoid pain. Patients learn to "self-regulate" by learning skills to decrease arousal and release tension. It teaches useful tools to assist the patient in taking less or no analgesics (and other abortive agents) which can lead to rebound headaches. Such physiological retraining helps to counter-condition the bracing responses (physical responses to pain, such as shallow breathing, clenched teeth)and hyperarousal that often result from (and perpetuate) frequent and/or severe head pain.
The skills learned during biofeedback training are quite helpful in reducing your anxiety during medication transitions. It allows you to develop a better internal locus of control with respect to management of pain and/or apprehension about pain. In addition, contact with a clinician between follow-up visits with the referring physician can be a valuable opportunity to reinforce medication compliance and serve as an additional opportunity to assess your progress and needs.
Generalization strategies are presented to encourage ongoing use of self-regulation skills. Patients learn exercises to repeat during the day as well as techniques that target pain once it starts. This serves to counteract apprehension at pain onset. The ultimate goal is to "overlearn" the responses involved in reducing arousal (and pain) so that these helpful responses seem to come naturally having to make conscious efforts to produce them.
Cognitive/Behavior Modification
A variety of cognitive styles have been shown to affect pain as well as the experience of suffering. Certain styles of thinking may serve to increase arousal or enhance the experience of pain. Examples of such cognitive styles include catastrophization, overgeneralization, and negativism. To catastrophize is to have expectations that the headache will be "more awful" or "intolerable" than it has been historically. Overgeneralization involves a belief system in which every headache will progress to an incapacitating level. Finally, negativism involves a belief that "nothing will be helpful... I am doomed." Such maladaptive cognitive styles tend to increase arousal and decrease one’s abilities to cope with pain.
In the therapeutic setting, styles of poor coping strategies are discussed with a goal of developing healthier coping strategies and eliminating negative thinking. Also worth exploring are behavioral issues such as time management, over-scheduling, and the amount of time the patient spends in pleasurable activities. If you exhibit "Type A" behavior, you may want to discuss modifications.
Frequent and/or severe pain can be a stressor in and of itself. Most patients are able to identify external stressors but forget that the experience of pain, from independent or external events, serves to maintain high levels of arousal. Hence, clinicians need to be sensitive about conveying an attitude to the patient that simple adjustments in lifestyle would guarantee that their headache problems would improve (e.g., "Maybe you need a less stressful job...Maybe you’re too stressed in your relationship"). It is usually not that simple, and pain and stress management techniques are best presented as part of a comprehensive treatment plan.
Participation in Headache Recovery
Your clinician or physician should enlist your active participation; doing so is probably the most crucial element in a successful therapeutic program. Compliance in keeping a headache calendar; avoiding overuse of analgesics, ergotamine, or triptan medications; following through with referrals; and adhering to the overall treatment plan worked out with the clinician should be closely monitored. Failure to comply with treatment recommendations should be considered a treatment issue that must be addressed.
Summary
Behavioral medicine programs (which are individualized to the specific needs of the patient) are appropriate treatment strategies for most headache patients, but are essential in the treatment of complicated and/or refractory headache problems. Successful treatment must be comprehensive and interdisciplinary. It is truly a joint effort by both you and your clinician.
