AAPB White Paper
Behavioral Approaches to Chronic Headache in Baltimore, MD
Steven M. Baskin, Ph.D. Frank Andrasik, Ph.D.

Chronic headache is considered to be one of the most prevalent of human diseases, regularly affecting approximately 45 million Americans. Seventy-six percent of women and 57% of men report at least one significant headache per month; over 90% have experienced some form of headache in their lifetime. Thirty-one percent of persons with headache have regular periods of disability. Headache complaints generate over 80 million physician office visits each year and cost business and industry over 150 million days of lost work per year. Lost productivity estimates for the US work force per year range from $6 to $20 billion. The Nuprin Pain Report designated headache as the most frequent pain-related cause of employee absenteeism in the US. In excess of $4 billion is spent annually on over-the-counter remedies for headache.

The two most common headache disorders are migraine and tension-type headache, with the latter being subdivided into 2 types, episodic and chronic. Migraine is most often experienced as a one-sided headache, throbbing in quality, with moderate to severe intensity that frequently decreases an individual's functional capacity. During the headache, other symptoms may occur as well, such as nausea, vomiting, and sensitivity to light and/or sound. Among migraine sufferers, 85% of females and 82% of males report some disability with each attack.

Tension-type headache, in its varied forms, is probably the most common headache disorder. Most people experience periodic or episodic tension-type headache under conditions of acute emotional, physical, or mental stress. The headache is described as mild to moderate in intensity and is most often experienced as a steady squeezing or pressing pain. It usually occurs on both sides of the head, in the forehead, temples, or back of the head and neck, but it may appear in all areas. Other symptoms are less frequent. If someone has tension-type headache greater than 15 days out of the month, this condition is termed chronic tension-type headache.

Individuals seen at headache specialty clinics most often have what has been termed transformed headache. That is, the headache began as an intermittent migraine, but over time progressed to a chronic, persistent daily headache, which is then a combination of migraine and chronic tension-type headache.

Historically, migraine was viewed as being due primarily to vascular problems, and tension-type headache was looked upon as being caused by excessive contractions of neck and scalp muscles. These straightforward accounts of headache have been called into question more recently for being too simplistic. It is now known that other causal factors are important, too, such as influences of the central nervous system and the chemical messengers that transmit pain signals (serotonin, for example). Vascular and muscular events are still recognized as important, but are being viewed more as secondary reactions.

The most current, comprehensive view of migraine seeks to unify accounts that include neurological, vascular, and "psychobiological" processes. The neurovascular account suggests that certain outside factors, such as hunger, fatigue, hormones, psychological stress, etc., can serve to trigger or activate headache when these factors exceed a built-in threshold for the individual. This activation causes blood vessels to expand, increases production of substances that further provoke pain, induces inflammation and swelling, and heightens the sensation of pain. Psychobiological models suggest that some built-in predisposition operates in the chronic headache patient that goes well beyond mere genetic variables. This position states that the generator, not the cause of severe headache attacks, is found more often in the person's psychobiological composition which includes not only genetics, but also learning history and biochemical makeup. The psychobiological model suggests that as a headache disorder becomes more severe and chronic, a complex process, which involves faulty learning and behavior, serves to maintain the disorder.

Many headache sufferers successfully treat their conditions by use of various types of home remedies and over-the-counter preparations. When physicians are consulted, chronic headaches are treated primarily by medication. These medications are used to help alleviate pain, to abort, interrupt, or shorten the duration of an ongoing headache, or to prevent a headache from ever occurring in the first place. Several different medications may be used in combination in an attempt to achieve 1 or more of these goals.

In the past 2+ decades, a number of behavioral approaches have been developed to provide further treatment options to chronic headache sufferers. Behavioral treatments, such as biofeedback, differ from medical approaches in a number of ways. Behavioral approaches place less emphasis on physical procedures or medications applied by others, place more emphasis on patient involvement and personal responsibility, expand the scope of treatment to include emotional, mental, behavioral, and social factors that often have a bearing on treatment, and seek to enable the person to cope more effectively with their pain and any problems that compound the pain. In practice, behavioral clinicians attempt to deal with various trigger factors, to instruct the person in ways to dampen bodily arousal as a way of directly impacting underlying mechanisms and promoting relaxation, and to manage any untoward consequences that may be serving to maintain headache and related suffering.

The most common behavioral approaches are relaxation, biofeedback, and stress coping training. Relaxation therapies use a variety of procedures to enable the person to achieve an overall relaxed state. This may be accomplished by engaging in a systematic series of muscle tensing and releasing exercises, by using meditative or mind quieting techniques, or by using components of autogenic training (concentrating on relaxing statements). Whereas relaxation targets the entire body, biofeedback targets specific bodily responses believed to underlie headache. Special sensors are used to monitor the response of interest and the information obtained from these sensors is presented to the person in an informative way that then allows him/her to regulate the response being monitored. For example, if heightened muscle tension is contributing to the person's headaches, then sensors are placed on the involved muscle and the person is taught how to reduce these contractions through the information or feedback provided. Biofeedback therapy for migraine involves learning how to control blood flow in the hands or in the temple area as a way of impacting headache. It is believed that this procedure stabilizes blood flow and also affects central nervous system processes (helps reduce nervous arousal or interrupt the "fight or flight" response). Stress coping training teaches people how to recognize trigger factors and reactions to headache so they can more directly deal with headache causes. These treatments are typically administered individually and require from 8 to 16 sessions. Researchers are now investigating other ways to administer these treatments in order to make them more convenient, affordable, and cost-effective (for example, by delivering treatment in groups or by decreasing the number of office visits and supplementing treatment with instructional manuals and audiocassettes to study at home).

Numerous studies have investigated the utility of relaxation and biofeedback treatments; fewer studies have examined the usefulness of stress coping training. Quantitative or statistical reviews show relaxation and biofeedback improvement rates of from 45-55% for people with migraine and from 46- 57 % for people with tension-type headache. These improvement rates exceed those obtained with various pseudo or inactive treatments (psychological or drug placebos). Combining treatments increases effectiveness somewhat, as does the addition of medication with behavioral treatment. Children appear to be especially good candidates for these types of treatments and respond at a greater level than do adults. Improvement rates for stress coping training are believed to be similar. Follow-up studies show that these treatments continue to retain their value years later. Although studies directly comparing behavioral and medication approaches are limited in number, statistical comparisons from pooled results reveal that biofeedback combined with relaxation rivals the effectiveness of one of the most commonly used medications for preventing migraines. Available data suggest that behavioral treatments, in addition to reducing painful episodes, can also lead to other important improvements. For example, upon completing behavioral treatment for headache, subsequent visits to physician offices, employee health centers, and hospital emergency rooms have been found to be reduced, medication usage and the need for special procedures often decreases, days of hospitalization are decreased, and subsequent total medical costs can be significantly reduced. One study showed that $5 and 1/2 were saved for every $1 spent on this type of treatment.

In summary, a number of behavioral treatment approaches have been shown to be of significant value in treating the most common forms of headache, migraine and tension-type. Chief among these behavioral approaches are relaxation, biofeedback, and stress coping training. These treatments often lead to significant improvements in other areas and subsequent reductions in costs of medical care.

Andrasik, F. (1990). Psychological and behavioral aspects of chronic headache. In N.T. Mathew (Ed.), Neurologic Clinics: Advances in Headache (Vol 8, pp. 961-976). Philadelphia: Saunders.

Andrasik, F., & Packard, R.C. (1989, June). Cost-effectiveness of biofeedback therapy for headache: A review. Paper presented at the annual meeting of the American Association for the Study of Headache, Boston, MA.

Bakal, D.A. (1982). The psychobiology of chronic headache. NY: Springer.

Linet, M.S., Stewart, W.F., Celentano, D.E. et al. (1989). An epidemiological study of headache among adolescents and young adults. Journal of the American Medical Association, 261, 2211-2216.

Saper, J.S., Silberstein, S., Gordon, C. D., & Hamel, R. (1993). Handbook of headache management. Baltimore: Williams & Wilkins.

Schneider, C.J. (1994). Cost-effectiveness of biofeedback and behavioral medicine treatments: A review of the literature. R. Shellenberger, P. Amar, C. Schneider, & J. Turner (Eds.), Clinical efficacy and cost-effectiveness of biofeedback therapy: Guidelines for third parry reimbursement (2nd ed.). Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback.

Taylor, H., & Curran, N.M. (1985). The Nuprin pain report. NY: Louis Harris and Assoc.

Ziegler, D.K. (1990). Headache: Public health problem. In N.T. Mathew (Ed.), Neurologic Clinics: Advances in Headache (Vol 8, pp. 781-791). Philadelphia: Saunders.