Behavioral Approaches to Headache Management Steven M. Baskin Ph.D New England Institute for Behavioral Medicine Stamford, Connecticut

Psychobiological Model The organic/psychogenic distinction is not useful Conditions that control chronic headache are multidimensional involving cognitive/emotional/ behavioral factors as well as biological processes

General Treatment Principles I The history is the heart of diagnosis and treatment A patient’s goals are individual The Headache Diary helps doctor to see patterns/ assess outcome Things that need to be stopped: – headache inducing medications – ineffective or unnecessary medications (including vitamins, herbs) – overuse of immediate relief medications

General Treatment Principles II Avoid / limit headache triggers Lifestyle management Evaluate other relevant medical conditions Optimize treatment of acute attacks Assess the need for preventive therapy Reassessment of the plan as needed

Headache History Grade the headache by its intensity/severity Incapacitating Moderate - severe Dull (operational definition) note characteristics of pain for each intensity headache frequency prodrome/aura location/laterality associated symptoms character of pain behavior during attack medication usage and relief time of onset/duration/ pain patterns

“If I don’t take the pills, all my headaches will be incapacitating.”

Rebound Headache “The worsening of head pain in chronic headache sufferers, caused by the frequent and excessive use of immediate relief medications.”

Accurately identify migraine onset Keep medication readily available Clear written instructions as to dosage repeating dosage and limits for abortive agents Specific titration schedules for preventives and strategies for side effect management To maximize Adherence To maximize Adherence

Prodromal Phenomena Psychologic – hypo or hyperactivity – mood changes up or down – irritability – restlessness Neurologic – light/sound sensitivity – cognitive changes – “off-balance” – language dysfunction – yawning – hyperosmia General – neck tightness – food cravings – cold feelings – decreased appetite – fatigue – GI changes – frequent urination – thirst – fluid retention

Behavioral Medicine Program Time-limited and goal oriented Active participation and personal responsibility Education Self-monitoring with headache diary Dietary and behavior changes Relaxation / biofeedback to foster self-regulation Cognitive strategies to enhance coping Maximize adherence to drug regimens Diagnose and treat coexisting psychiatric problems both pharmacologically and psychologically

General Hints for Headache Control Maintain consistent biological rhythms Sleep/wake patterns consistent including weekends Avoid oversleeping Same bedtime/ time of awakening Eat nutritious meals at regular intervals Increase aerobic exercise _______________________________________________________________ ____________________________________________________________

Stress Management Training Acute Migraine Preparing for a migraine The beginning of the headache As intensity builds Coping with thoughts and feelings at critical moments Self-reflection and evaluation