BEHAVIORAL MIGRAINE MANAGEMENT

BEHAVIORAL MIGRAINE BEHAVIORAL MIGRAINE MANAGEMENTMANAGEMENT

Kenneth A. Holroyd, Ph.D.Ohio University

Behavioral TreatmentsBehavioral Treatments

• Relaxation Therapy

• Biofeedback Therapy

• Cognitive-Behavior (Stress-Management) Therapies

• Combinations of the above treatments

Relaxation TrainingRelaxation Training

• Types of Relaxation Training– Progressive muscle relaxation

– Autogenic training

– Meditation or passive relaxation

...I’m telling you, Ed. You’ve got to learn to deal with tension better

Relaxation TrainingRelaxation Training• Relaxation training involves a specific set of

procedures not just “trying to relax”– Individuals adapt to chronic muscle tension

• May not recognize tension or relaxation• May not know how to relax

– Progressive muscle relaxation procedure• Begins with tensing & relaxing 12 muscle groups (25

min)• Proceeds in steps to quick cue controlled relaxation that

can be used throughout the day– Goals of relaxation training include

• Increase awareness of early signs of headache onset• Use relaxation to prevent and abort headaches• Increase personal sense of control (self-efficacy)

Biofeedback TrainingBiofeedback Training• Monitor headache-related physiological

responses

• Present information (“feedback”) about physiological response (e.g., audio tone)

• Patient uses “feedback” to learn to regulate the response

Biofeedback TrainingBiofeedback Training

Types of Biofeedback TrainingTypes of Biofeedback Training• Electromyographic (EMG) Biofeedback

– Typically for tension-type headache

• Thermal (“hand-warming’) biofeedback– Typically for migraine

• Other– Cephalic vasomotor biofeedback– GSR feedback, Neurofeedback (EEG)

Biofeedback TrainingBiofeedback Training• EMG Biofeedback

– May be effective in in individuals who are unable to master relaxation training

– May enable deeper muscle relaxation than relaxation training

– May be accepted by patients who are averse to psychological treatment

• Thermal Biofeedback– Hand-warming may require weeks of practice to

learn– Hand-warming response is used primarily to

prevent, but also to abort migraines

Cognitive-Behavioral Stress-Cognitive-Behavioral Stress-Management TherapyManagement Therapy

• Teach patients to:– Identify & manage stress-generating

thoughts & beliefs • Prevent stress-related headaches• Manage pain, distress & disability when

headaches occur.• Manage psychological consequences (e.g.,

depression, helplessness) of headaches


• Thought Monitoring: – Identify stress-generating thoughts &

“underlying” beliefs• Skills training:

– Teach cognitive (e.g., self-talk) and behavioral (e.g., ) coping skills

• Application:– Apply skills in progressively more

challenging situations.


• Stress-Generating Thoughts– Catastrophizing

• I wonder whether something serious may happen• I keep thinking how much it hurts

• Stress- Generating Beliefs– Expecting Perfectionism– Expecting Approval

Holroyd et al., 2005


• Stress-Generating Thoughts– Recognizing & challenging thoughts– Coping “Self-Talk”

• Stress-Generating Beliefs– Reversing Positions– Reframing– Reality Testing

Management of Migraine in Management of Migraine in Primary Care SettingsPrimary Care Settings

Evidence-Based Treatment GuidelineEvidence-Based Treatment Guideline

• American Academy of Family Physicians• American Academy of Neurology• American Headache Society• American College of Emergency Physicians• American College of Physicians• American Osteopathic Association• National Headache Foundation

• Diagnostic and Neuroimaging• Acute Treatment• Preventive Treatment• Behavioral and Physical Treatment

U.S. Headache Treatment Guideline

ConsortiumMember

Organizations

GuidelineComponents

Literature on Behavioral TreatmentsLiterature on Behavioral Treatments

• 355 articles identified• 70 controlled trials identified• 39 prospective, randomized, controlled

trials aimed at prevention of migraine attacks met all data extraction requirements

Statistical AnalysisStatistical Analysis

• “Effect Size” (each treatment comparison) = standardized difference between group means

• “Percentage Improvement” = [pre-tx - post-tx/pre-tx score] X 100

• Summary Statistics:– summary ES using random effects model– avg. % improvement weighted by sample size

Efficacy of Behavioral Treatments for Migraines

Percentage Improvement-40 -20 0 20 40 60 80

Control (12)

RLX (5)

TBF + RLX (8)

EMG - BF (3)

CBT(5)

Effect size

-1.0 -0.5 0.0 0.5 1.0 1.5 2.0

Mean Effect Size% Improvement

95% CI

Meta-Analysis of Behavioral vs. Pharmacologic Meta-Analysis of Behavioral vs. Pharmacologic Treatment of Migraine Treatment of Migraine (% change)(% change)

-20

020

4060

Wai

t-lis

tco

ntro

l

Plac

ebo

Med

icat

ion

BF

+ R

LX

Prop

rano

lol

Flun

ariz

ine

Perc

ent I

mpr

ovem

ent

Holroyd & Penzien '90; Holroyd, Corgingley &Penzien, '91; Davis, Holroyd & Penzien '99

Specific Treatment RecommendationsSpecific Treatment Recommendations

Findings: • RLX, BF, and CBT

are all somewhat effective in preventing migraine when compared with controls.

Recommendation • RLX, BF, and CBT

may be considered as treatment options for prevention of migraine (Grade A Evidence)

Specific Treatment RecommendationsSpecific Treatment Recommendations

Findings:

Behavioral treatments have been directly compared and combined with drug treatments for migraine. Propranolol conferred additional benefits when added BF, and CBT.

Recommendation Behavioral therapy may

be combined with preventive drug therapy to achieve additional clinical improvement (Grade B Evidence)

Meta-analysis of Pediatric Migraine Meta-analysis of Pediatric Migraine TreatmentsTreatments

0

0.2

0.4

0.6

0.8

1

1.2

Effe

ct S

ize

Behavioral Drug

Treatment Effects

BEHAVIORAL THERAPIESThermal BiofeedbackAutogenic TrainingDRUG THERAPIESPropranololCalcium-Channel Blockers Seroternergic DrugsPlacebo

Herman, Kim & Blanchard, 1995

Pediatric MigrainePediatric Migraine

• Readily learn control of physiological response

• High response rate to behavioral interventions

• Game-like task involves child

• Skills can be used into adulthood

• Limited drug options

Telephone Administered Behavioral Telephone Administered Behavioral TreatmentTreatment

• % Exhibit Headache Management Skills in Clinic– 100% ≥ 1 skill– 67% ≥ 2 skills – 27% ≥ 3 skills

• Relaxation, partial relaxation, diaphragmatic breathing, thermal biofeedback

-10%

10%

30%

50%

70%

TreatmentFormat

% Adolescents Clinically Improved

ControlClinicTelephone

T

McGrath et al. (1992)Corrtell et al., in preparation

Behavioral Migraine ManagementBehavioral Migraine Management

• Overview Basic Migraine Management Skills

Relaxation Skills Identifying & Managing Migraine Triggers Recognizing & Responding to early Warning

Signs Effectively Using & Evaluating Migraine

Medications Coping with Migraines

Behavioral Migraine ManagementBehavioral Migraine Management

• Advanced Migraine Management Skills A. Hand-warming

• Learning hand-warming • Applying hand-warming to prevent migraines

orB. Stress Management

• Identifying & challenging stress- generating thoughts • Identifying & challenging stress-generating beliefs • Applying stress-management skills

Headache Locus of ControlHeadache Locus of Control

• Health Professionals Scale– Only my doctor can give me ways to prevent

headaches– If I don’t have the right medication, my headaches

will be a problem– My headaches can be less severe if medical

professionals take proper care of me

Headache Locus of ControlHeadache Locus of Control

• Internal Locus of Control– I can prevent some of my headaches by avoiding

certain stressful situations– My headaches are sometimes worse because I am

overactive– If I can remember to relax I can avoid some of my

headaches

Self-Efficacy BeliefsSelf-Efficacy Beliefs• Self-Efficacy = Confidence that one can

perform headache management activities • Self-efficacy:

– Is assessed for a specific domain– Is assessed with reference to specific behaviors– Is highly malleable

Headache Self-Efficacy Scale Headache Self-Efficacy Scale • Headache Prevention:

– I can prevent some of my headaches by recognizing headache triggers

• Disability Management:– I can can keep a mild headache from

disrupting my day by changing the way I respond to pain

TCTH TRIAL: INITIAL TREATMENT TCTH TRIAL: INITIAL TREATMENT PHASEPHASE

AM + Clinical Management

Placebo + Clinical Management

SMT+ Placebo Baseline Reevaluation

SMT + AM

4 weeks 12 weeks 4 weeks

SAMPLE CHARACTERISTICS SAMPLE CHARACTERISTICS (N = 203)(N = 203)

• Diagnosis: All patients IHS 2. 2 CTH; 25% co-morbid migraine diagnosis; IHS 8.2 excluded

• Gender: 77% female

• Age: M = 37.0 years

• Race: 95% Caucasian

• Frequency : M = 26.0 headache days/ month

• Chronicity: M = 12.5 years problem headaches

0 1 2 1 2 3 4 5 6 7 8 9 10 11 12

30

35

40

45

50

HSL

C -

Inte

rnal

Month

PlaceboAntidepressant MedicationStress Management TherapyAntidepressant Medication Plus Stress Management Therapy

Bl Tx Evaluation

0 1 2 1 2 3 4 5 6 7 8 9 10 11 12

20

25

30

35

40

HSL

C -

Prof

essi

onal

Month


Bl Tx Evaluation

0 1 2 1 2 3 4 5 6 7 8 9 10 11 12

80

100

120

140

160

Hea

dach

e Se

lf-Ef

ficac

y

Month


Bl Tx Evaluation

0 1 2 1 2 3 4 5 6 7 8 9 10 11 12

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Posi

tive

Con

trol S

trate

gies

Month


Bl Tx Evaluation

0 1 2 1 2 3 4 5 6 7 8 9 10 11 12

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Posi

tive

Prev

enta

tive

Stra

tegi

es

Month


Bl Tx Evaluation

ConclusionsConclusions

• Behavioral Migraine Management (BMM)– Combines behavioral interventions in an integrated treatment

package

– BMM can improve migraines and quality of life

– BMM can help empower patients to be actively involved in the management of their migraines

– BMM is a promising intervention for the management of migraines in adolescents

• Telephone administration may make BMM more accessible to adolescents

BEHAVIORAL MIGRAINE MANAGEMENT

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