Transcript of headaches Cognitive-Behavioral Stress

BEHAVIORAL MIGRAINE
MANAGEMENT
Kenneth A. Holroyd, Ph.D.
Ohio University
Behavioral Treatments
• Relaxation Therapy
• Biofeedback Therapy
• Cognitive-Behavior (Stress-Management)
Therapies
• Combinations of the above treatments
Relaxation 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 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 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 Training
Types 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 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 StressManagement 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
Cognitive-Behavioral StressManagement Therapy
• 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.
Cognitive-Behavioral StressManagement Therapy
• 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
Cognitive-Behavioral StressManagement Therapy
• Stress-Generating Thoughts
– Recognizing & challenging thoughts
– Coping “Self-Talk”
• Stress-Generating Beliefs
– Reversing Positions
– Reframing
– Reality Testing
Management of Migraine in
Primary Care Settings
Evidence-Based Treatment Guideline
U.S.
Headache
Treatment
Guideline
Consortium
Member
Organizations
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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
Guideline
Components
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•
•
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Diagnostic and Neuroimaging
Acute Treatment
Preventive Treatment
Behavioral and Physical Treatment
Literature 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 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
Effect size
-1.0
-0.5
0.0
0.5
1.0
1.5
2.0
-20
0
20
40
60
80
CBT(5)
EMG - BF (3)
TBF + RLX (8)
RLX (5)
Control (12)
-40
Percentage Improvement
% Improvement
Mean Effect Size
95% CI
40
20
Flunarizine
Propranolol
BF + RLX
Placebo
Medication
Wait-list
control
0
-20
Percent Improvement
60
Meta-Analysis of Behavioral vs. Pharmacologic
Treatment of Migraine (% change)
Holroyd & Penzien '90; Holroyd, Corgingley &
Penzien, '91; Davis, Holroyd & Penzien '99
Specific 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 Recommendations
Findings:
Recommendation
Behavioral treatments have Behavioral therapy may
been directly compared
be combined with
and combined with drug
preventive drug therapy
treatments for migraine.
to achieve additional
Propranolol conferred
clinical improvement
additional benefits when
added BF, and CBT.
(Grade B Evidence)
Meta-analysis of Pediatric Migraine
Treatments
Treatment Effects
1.2
Effect Size
1
BEHAVIORAL THERAPIES
Thermal Biofeedback
Autogenic Training
DRUG THERAPIES
Propranolol
Calcium-Channel Blockers
Seroternergic Drugs
Placebo
0.8
0.6
0.4
0.2
0
Behavioral
Drug
Herman, Kim & Blanchard, 1995
Pediatric 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
Treatment
• % Exhibit Headache
Management Skills in Clinic
– 100% ≥ 1 skill
% Adolescents
Clinically Improved
– 67% ≥ 2 skills
70%
– 27% ≥ 3 skills
50%
T
30%
• Relaxation, partial
relaxation, diaphragmatic
breathing, thermal
biofeedback
Corrtell et al., in preparation
10%
Control
Clinic
Telephone
-10%
Treatment
Format
McGrath et al. (1992)
Behavioral 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 Management
•
Advanced Migraine Management
Skills
A. Hand-warming
• Learning hand-warming
• Applying hand-warming to prevent migraines
or
B. Stress Management
• Identifying & challenging stress- generating thoughts
• Identifying & challenging stress-generating beliefs
• Applying stress-management skills
Headache 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 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 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 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
PHASE
AM + Clinical Management
Placebo + Clinical Management
SMT+ Placebo
Baseline
Reevaluation
SMT + AM
4 weeks
12 weeks
4 weeks
SAMPLE CHARACTERISTICS
(N = 203)
• Diagnosis:
• Gender:
All patients IHS 2. 2 CTH;
25% co-morbid migraine diagnosis;
IHS 8.2 excluded
77% female
• Age:
M = 37.0 years
• Race:
95% Caucasian
• Frequency :
M = 26.0 headache days/ month
• Chronicity:
M = 12.5 years problem headaches
Placebo
Antidepressant Medication
Stress Management Therapy
Antidepressant Medication Plus Stress Management Therapy
HSLC - Internal
50
45
40
35
30
0
Bl
1
2
Tx
1
2
3
4
5
6
7
Month
Evaluation
8
9
10
11
12
Placebo
Antidepressant Medication
Stress Management Therapy
Antidepressant Medication Plus Stress Management Therapy
HSLC - Professional
40
35
30
25
20
0
Bl
1
2
Tx
1
2
3
4
5
6
7
Month
Evaluation
8
9
10
11
12
Placebo
Antidepressant Medication
Stress Management Therapy
Antidepressant Medication Plus Stress Management Therapy
Headache Self-Efficacy
160
140
120
100
80
0
Bl
1
2
Tx
1
2
3
4
5
6
7
Month
Evaluation
8
9
10
11
12
Placebo
Antidepressant Medication
Stress Management Therapy
Antidepressant Medication Plus Stress Management Therapy
Positive Control Strategies
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0
Bl
1
2
Tx
1
2
3
4
5
6
7
Month
Evaluation
8
9
10
11
12
Positive Preventative Strategies
Placebo
Antidepressant Medication
Stress Management Therapy
Antidepressant Medication Plus Stress Management Therapy
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0
Bl
1
2
Tx
1
2
3
4
5
6
7
Month
Evaluation
8
9
10
11
12
Conclusions
• 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