Behavioral Therapy for Migraine and Tension-Type Headache

Steven M. Baskin, PhD, a clinical psychologist at the New England Institute for Neurology and Headache in Stamford, Connecticut, recently answered the Migraine Resource Center’s questions about the benefits of behavioral therapy in the treatment of migraine and tension-type headache.
 

Alan M. Rapoport, MD: Could you please give a brief description of the 5 best modalities of behavioral therapy for migraine and tension-type headache? 
 

Steven M. Baskin, PhD: The most researched modalities that have a good evidence base for both migraine and tension-type headache (TTHA) are relaxation therapies that often combine abdominal breathing with some form of progressive relaxation, electromyography (EMG) biofeedback therapy where headache patients learn to decrease scalp and neck muscle tension utilizing muscular biofeedback, thermal biofeedback where migraine sufferers learn a way to warm their hands which often creates a low arousal state that may reduce brain hyperexcitability, and cognitive behavioral therapy (CBT) techniques to learn stress management. The combination of behavioral medicine techniques plus preventive pharmacological treatment has been showed to be more efficacious than either treatment alone. (Holroyd KA, et al. Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial. BMJ. 2010;1-12)

CBT to treat insomnia has also been shown to reverse many chronic migraine sufferers back to episodic migraine. (Smitherman TA, et al. Cognitive-Behavioral Therapy for Insomnia to Reduce Chronic Migraine: A Sequential Bayesian Analysis. Headache 2018;58:1052-1059)
 

Dr. Rapoport: How do you identify a patient who may benefit from behavioral therapy over acute medication, and what is the first step that you suggest?
 

Dr. Baskin: Behavioral therapies for migraine management are typically preventive therapies that can and should be combined with medications to control acute attacks. There are behavioral principles that can maximize adherence to abortive agents in order to optimize acute care.
 

Dr. Rapoport: Which tends to work the best for migraine?
 

Dr. Baskin: What works best is to first do a good behavioral assessment of the frequency, duration, intensity, and disability level of their headaches as well as current stress levels, history, and adherence to drug and nondrug therapies, and psychiatric comorbidities. A program should then be developed that includes some combination of pharmacological and behavioral interventions to address these issues. It is important to increase self-efficacy: patients’ belief in the ability to control the headache, belief in the ability to manage emotional reactivity to pain, and belief that they can achieve functionality in the presence of a significant headache disorder.
 

Dr. Rapoport: Who should not have biofeedback therapy?
 

Dr. Baskin: Biofeedback has shown to be effective in treating migraine and TTHA. It has not been shown to be effective in treating trigeminal autonomic cephalgias (TACs) such as cluster headache. Like pharmacological therapies, it is less effective in chronic migraine that is daily and constant. A patient with severe psychiatric disorder should be treated for their psychiatric disorder before beginning biofeedback therapy.
 

Dr. Rapoport: Some doctors see patients twice per week for several months. What is your typical routine for behavioral therapy?
 

Dr. Baskin: We have a variety of programs. For complicated patients, we tend to see them weekly and have a very systematic program of biofeedback and CBT for approximately 12 to 15 sessions. This may include treating psychiatric comorbidities. We see many other patients for 1 or 2 sessions of biofeedback to try to effect physiological learning and for 1 or 2 sessions of CBT to help them manage stressors and learn coping skills that they can use to help manage migraines and life stress.
 

Dr. Rapoport: Does behavioral medicine work best in conjunction with preventive medications, or on its own?

Dr. Baskin: Many patients do well with a behavioral treatment as a preventive therapy and a pharmacologic agent to optimize acute care. I believe that many patients with higher frequency migraine with psychological issues or ongoing stressors do best with a combination of preventive pharmacologic therapy and behavior therapy. Any migraine patient with sleep issues should learn CBT for insomnia. 

Dr. Rapoport: Is there evidence that suggests behavioral therapy can help patients at various ages manage their migraines?

Dr. Baskin: There is both adult and child data on behavioral therapy for migraine.  An excellent study was done in children and adolescents by Powers et al. It showed that adding 10 sessions of CBT to preventive amitriptyline therapy, compared to adding headache education, significantly reduced the number of headache days, level of disability, and kids with a better than 50% decrease in days of headache compared to amitriptyline, plus headache education control in chronic migraine patients.  (Powers SW et al. Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents: A Randomized Clinical Trial. JAMA 2013;310(24):2622-2630)

Dr. Rapoport: A recent MedPage Today article noted that “anxiety may complicate migraine more than depression with greater long-term persistence, greater headache-related disability, and reduced satisfaction with acute therapies.” Could you please elaborate on why this may be the case? 

Dr. Baskin: Anxiety disorders are often based on feeling threat. They are always associated with avoidance behaviors. Headache sufferers with significant anxiety tend to overestimate the probability of danger (migraine) and perceive it as more unmanageable and threatening than objective reality. They are often very sensitive to medication side effects and benign somatic sensations. They sometimes take medications pre-emptively, because of their fear of getting a migraine, which may lead to medication misuse or overuse. The lifetime prevalence of anxiety disorders in migraineurs (ranging from 51-58%) is almost twice that of major depression.

Please write to us at Neurology Reviews Migraine Resource Center (mrc@mdedge.com) with your opinions.

Alan M. Rapoport, M.D.

Editor-in-Chief

Migraine Resource Center

Clinical Professor of Neurology

The David Geffen School of Medicine at UCLA

Los Angeles, California

Steven M. Baskin, PhD, a clinical psychologist at the New England Institute for Neurology and Headache in Stamford, Connecticut, recently answered the Migraine Resource Center’s questions about the benefits of behavioral therapy in the treatment of migraine and tension-type headache.
 

Alan M. Rapoport, MD: Could you please give a brief description of the 5 best modalities of behavioral therapy for migraine and tension-type headache? 
 

Steven M. Baskin, PhD: The most researched modalities that have a good evidence base for both migraine and tension-type headache (TTHA) are relaxation therapies that often combine abdominal breathing with some form of progressive relaxation, electromyography (EMG) biofeedback therapy where headache patients learn to decrease scalp and neck muscle tension utilizing muscular biofeedback, thermal biofeedback where migraine sufferers learn a way to warm their hands which often creates a low arousal state that may reduce brain hyperexcitability, and cognitive behavioral therapy (CBT) techniques to learn stress management. The combination of behavioral medicine techniques plus preventive pharmacological treatment has been showed to be more efficacious than either treatment alone. (Holroyd KA, et al. Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial. BMJ. 2010;1-12)

CBT to treat insomnia has also been shown to reverse many chronic migraine sufferers back to episodic migraine. (Smitherman TA, et al. Cognitive-Behavioral Therapy for Insomnia to Reduce Chronic Migraine: A Sequential Bayesian Analysis. Headache 2018;58:1052-1059)
 

Dr. Rapoport: How do you identify a patient who may benefit from behavioral therapy over acute medication, and what is the first step that you suggest?
 

Dr. Baskin: Behavioral therapies for migraine management are typically preventive therapies that can and should be combined with medications to control acute attacks. There are behavioral principles that can maximize adherence to abortive agents in order to optimize acute care.
 

Dr. Rapoport: Which tends to work the best for migraine?
 

Dr. Baskin: What works best is to first do a good behavioral assessment of the frequency, duration, intensity, and disability level of their headaches as well as current stress levels, history, and adherence to drug and nondrug therapies, and psychiatric comorbidities. A program should then be developed that includes some combination of pharmacological and behavioral interventions to address these issues. It is important to increase self-efficacy: patients’ belief in the ability to control the headache, belief in the ability to manage emotional reactivity to pain, and belief that they can achieve functionality in the presence of a significant headache disorder.
 

Dr. Rapoport: Who should not have biofeedback therapy?
 

Dr. Baskin: Biofeedback has shown to be effective in treating migraine and TTHA. It has not been shown to be effective in treating trigeminal autonomic cephalgias (TACs) such as cluster headache. Like pharmacological therapies, it is less effective in chronic migraine that is daily and constant. A patient with severe psychiatric disorder should be treated for their psychiatric disorder before beginning biofeedback therapy.
 

Dr. Rapoport: Some doctors see patients twice per week for several months. What is your typical routine for behavioral therapy?
 

Dr. Baskin: We have a variety of programs. For complicated patients, we tend to see them weekly and have a very systematic program of biofeedback and CBT for approximately 12 to 15 sessions. This may include treating psychiatric comorbidities. We see many other patients for 1 or 2 sessions of biofeedback to try to effect physiological learning and for 1 or 2 sessions of CBT to help them manage stressors and learn coping skills that they can use to help manage migraines and life stress.
 

Dr. Rapoport: Does behavioral medicine work best in conjunction with preventive medications, or on its own?

Dr. Baskin: Many patients do well with a behavioral treatment as a preventive therapy and a pharmacologic agent to optimize acute care. I believe that many patients with higher frequency migraine with psychological issues or ongoing stressors do best with a combination of preventive pharmacologic therapy and behavior therapy. Any migraine patient with sleep issues should learn CBT for insomnia. 

Dr. Rapoport: Is there evidence that suggests behavioral therapy can help patients at various ages manage their migraines?

Dr. Baskin: There is both adult and child data on behavioral therapy for migraine.  An excellent study was done in children and adolescents by Powers et al. It showed that adding 10 sessions of CBT to preventive amitriptyline therapy, compared to adding headache education, significantly reduced the number of headache days, level of disability, and kids with a better than 50% decrease in days of headache compared to amitriptyline, plus headache education control in chronic migraine patients.  (Powers SW et al. Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents: A Randomized Clinical Trial. JAMA 2013;310(24):2622-2630)

Dr. Rapoport: A recent MedPage Today article noted that “anxiety may complicate migraine more than depression with greater long-term persistence, greater headache-related disability, and reduced satisfaction with acute therapies.” Could you please elaborate on why this may be the case? 

Dr. Baskin: Anxiety disorders are often based on feeling threat. They are always associated with avoidance behaviors. Headache sufferers with significant anxiety tend to overestimate the probability of danger (migraine) and perceive it as more unmanageable and threatening than objective reality. They are often very sensitive to medication side effects and benign somatic sensations. They sometimes take medications pre-emptively, because of their fear of getting a migraine, which may lead to medication misuse or overuse. The lifetime prevalence of anxiety disorders in migraineurs (ranging from 51-58%) is almost twice that of major depression.

Please write to us at Neurology Reviews Migraine Resource Center (mrc@mdedge.com) with your opinions.

Alan M. Rapoport, M.D.

Editor-in-Chief

Migraine Resource Center

Clinical Professor of Neurology

The David Geffen School of Medicine at UCLA

Los Angeles, California

Steven M. Baskin, PhD, a clinical psychologist at the New England Institute for Neurology and Headache in Stamford, Connecticut, recently answered the Migraine Resource Center’s questions about the benefits of behavioral therapy in the treatment of migraine and tension-type headache.
 

Alan M. Rapoport, MD: Could you please give a brief description of the 5 best modalities of behavioral therapy for migraine and tension-type headache? 
 

Steven M. Baskin, PhD: The most researched modalities that have a good evidence base for both migraine and tension-type headache (TTHA) are relaxation therapies that often combine abdominal breathing with some form of progressive relaxation, electromyography (EMG) biofeedback therapy where headache patients learn to decrease scalp and neck muscle tension utilizing muscular biofeedback, thermal biofeedback where migraine sufferers learn a way to warm their hands which often creates a low arousal state that may reduce brain hyperexcitability, and cognitive behavioral therapy (CBT) techniques to learn stress management. The combination of behavioral medicine techniques plus preventive pharmacological treatment has been showed to be more efficacious than either treatment alone. (Holroyd KA, et al. Effect of preventive (β blocker) treatment, behavioural migraine management, or their combination on outcomes of optimised acute treatment in frequent migraine: randomised controlled trial. BMJ. 2010;1-12)

CBT to treat insomnia has also been shown to reverse many chronic migraine sufferers back to episodic migraine. (Smitherman TA, et al. Cognitive-Behavioral Therapy for Insomnia to Reduce Chronic Migraine: A Sequential Bayesian Analysis. Headache 2018;58:1052-1059)
 

Dr. Rapoport: How do you identify a patient who may benefit from behavioral therapy over acute medication, and what is the first step that you suggest?
 

Dr. Baskin: Behavioral therapies for migraine management are typically preventive therapies that can and should be combined with medications to control acute attacks. There are behavioral principles that can maximize adherence to abortive agents in order to optimize acute care.
 

Dr. Rapoport: Which tends to work the best for migraine?
 

Dr. Baskin: What works best is to first do a good behavioral assessment of the frequency, duration, intensity, and disability level of their headaches as well as current stress levels, history, and adherence to drug and nondrug therapies, and psychiatric comorbidities. A program should then be developed that includes some combination of pharmacological and behavioral interventions to address these issues. It is important to increase self-efficacy: patients’ belief in the ability to control the headache, belief in the ability to manage emotional reactivity to pain, and belief that they can achieve functionality in the presence of a significant headache disorder.
 

Dr. Rapoport: Who should not have biofeedback therapy?
 

Dr. Baskin: Biofeedback has shown to be effective in treating migraine and TTHA. It has not been shown to be effective in treating trigeminal autonomic cephalgias (TACs) such as cluster headache. Like pharmacological therapies, it is less effective in chronic migraine that is daily and constant. A patient with severe psychiatric disorder should be treated for their psychiatric disorder before beginning biofeedback therapy.
 

Dr. Rapoport: Some doctors see patients twice per week for several months. What is your typical routine for behavioral therapy?
 

Dr. Baskin: We have a variety of programs. For complicated patients, we tend to see them weekly and have a very systematic program of biofeedback and CBT for approximately 12 to 15 sessions. This may include treating psychiatric comorbidities. We see many other patients for 1 or 2 sessions of biofeedback to try to effect physiological learning and for 1 or 2 sessions of CBT to help them manage stressors and learn coping skills that they can use to help manage migraines and life stress.
 

Dr. Rapoport: Does behavioral medicine work best in conjunction with preventive medications, or on its own?

Dr. Baskin: Many patients do well with a behavioral treatment as a preventive therapy and a pharmacologic agent to optimize acute care. I believe that many patients with higher frequency migraine with psychological issues or ongoing stressors do best with a combination of preventive pharmacologic therapy and behavior therapy. Any migraine patient with sleep issues should learn CBT for insomnia. 

Dr. Rapoport: Is there evidence that suggests behavioral therapy can help patients at various ages manage their migraines?

Dr. Baskin: There is both adult and child data on behavioral therapy for migraine.  An excellent study was done in children and adolescents by Powers et al. It showed that adding 10 sessions of CBT to preventive amitriptyline therapy, compared to adding headache education, significantly reduced the number of headache days, level of disability, and kids with a better than 50% decrease in days of headache compared to amitriptyline, plus headache education control in chronic migraine patients.  (Powers SW et al. Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents: A Randomized Clinical Trial. JAMA 2013;310(24):2622-2630)

Dr. Rapoport: A recent MedPage Today article noted that “anxiety may complicate migraine more than depression with greater long-term persistence, greater headache-related disability, and reduced satisfaction with acute therapies.” Could you please elaborate on why this may be the case? 

Dr. Baskin: Anxiety disorders are often based on feeling threat. They are always associated with avoidance behaviors. Headache sufferers with significant anxiety tend to overestimate the probability of danger (migraine) and perceive it as more unmanageable and threatening than objective reality. They are often very sensitive to medication side effects and benign somatic sensations. They sometimes take medications pre-emptively, because of their fear of getting a migraine, which may lead to medication misuse or overuse. The lifetime prevalence of anxiety disorders in migraineurs (ranging from 51-58%) is almost twice that of major depression.

Please write to us at Neurology Reviews Migraine Resource Center (mrc@mdedge.com) with your opinions.

Alan M. Rapoport, M.D.

Editor-in-Chief

Migraine Resource Center

Clinical Professor of Neurology

The David Geffen School of Medicine at UCLA

Los Angeles, California