Behavioral Medicine Approaches to Migraine

Steven M. Baskin, PhD

Multiaxial Assessment

All workups for headache evaluate frequency, intensity, duration, and disability. From a behavioral perspective, Dr. Baskin recommended considering a few more factors—adherence to therapy, stress-related issues, comorbid psychiatric disorders, and factors that transform migraine from episodic to chronic.

“When you talk about adherence, one of the basics of this is readiness to change,” said Dr. Baskin. “Is the patient motivated for treatment? That doesn’t necessarily happen immediately.” For example, a patient who is motivated to have an abortive agent might not be motivated to pursue prevention, lose weight, exercise, or make lifestyle changes. “Over time, that might change,” Dr. Baskin noted. Patient motivation may evolve with a greater understanding of the goals of treatment.

“Has the patient adhered to past therapy regimens? If the answer is no, then the answer will most likely be no again,” Dr. Baskin said. If medication overuse was a problem, it may be again. Whenever possible, ask open-ended questions, such as “how do you decide when to take an acute medication?” Dr. Baskin advised.

Stress and Migraine

High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic. “Patients with depression show a greater effect of stress,” Dr. Baskin said. Similarly, victims of trauma or childhood maltreatment can have more disabling headaches that may be more likely to transform into daily headaches. “Many patients do not have the coping skills necessary to manage stress or recurrent headache,” Dr. Baskin said. One of the goals of behavioral therapy for migraine is to increase patients’ self-efficacy and give them the tools and the confidence to manage headaches and stressors.

Psychiatric Comorbidity

Psychiatric comorbidity may complicate differential diagnosis, and nonadherence to medication is greater in people with mood disorders and anxiety disorders. These patients may show a reduced response to pharmacologic and behavioral treatments for headache. Psychiatric comorbidities also can contribute to migraine chronification. “However, if you add a small behavioral component to your headache program, patients with psychiatric comorbidities seem to respond relatively well,” Dr. Baskin said.

Migraineurs have a two- to threefold greater prevalence of depression. There is a bidirectional relationship between migraine and depression in population studies. The relationship between migraine and depression is greater in clinic populations, in chronic migraine, and in medication overuse headache.

There is a significant relationship between migraine and anxiety disorders. Anxiety disorders entail a sense of danger, fear, or worry. “All patients with anxiety disorder have physical symptoms, and they often show avoidance behaviors,” said Dr. Baskin. For example, in generalized anxiety disorder, the object of avoidance is probably the fear of uncertainty. People worry excessively, thinking they are avoiding uncertainty. “Avoidance learning is huge in anxiety,” said Dr. Baskin. People fear unexpected events and perceive things as more unmanageable, dangerous, or threatening than they objectively are. “We see that frequently in migraineurs with anxiety disorders,” he said. Dr. Baskin noted that anxious patients tend to be sensitive to medication side effects and somatic sensations in general.

Patients with headache and anxiety often develop strong fear reactions. They identify a warning signal for headache, real or imagined, and may treat their fear, which they perceive as a headache prodrome, with a medication. “There is a preemptive strike with medicine treating a sensation that may or may not develop into headache,” Dr. Baskin said. That medication reduces their emotional distress and prevents the migraine, a powerful avoidance learning paradigm. That cycle can be a major part of medication overuse headache.

Anxiety disorders are much more prevalent than depression in migraineurs. They are associated with greater long-term persistence of headache, greater headache-related disability, and reduced satisfaction with acute therapy. “Across all emotional disorders, anxiety is the driver of distress,” Dr. Baskin said. “When you add anxiety to any disorder, it becomes much more problematic.”

The concept of interoceptive awareness—an individual’s sensitivity to bodily signals—is important in people with panic disorder. Like people with panic disorder, some migraineurs often have high interoceptive awareness. Anxiety sensitivity—fear that benign physical sensations will have harmful or catastrophic consequences—also may be a factor in panic disorder, as well as migraine. As in panic disorder, highly anxious migraineurs may develop hypervigilance to somatic sensations and conditioned fear to these internal sensations.

Dr. Baskin recommends screening patients for psychiatric comorbidity. He recommends two questions from the Patient Health Questionnaire-9 screener—“Do you have little interest or pleasure in doing things?” and “Are you feeling down, depressed, or hopeless?”—and two additional anxiety questions—“Are you feeling anxious, nervous, or on edge?” and “Are you unable to stop or control worrying?” “With just those four questions, you can capture a good number of people with anxiety or mood issues,” Dr. Baskin said.

Behavioral Therapy

“Our behavioral medicine program is time-limited and goal-oriented,” said Dr. Baskin. “We try to get people to develop self-efficacy and personal responsibility. We monitor and maximize adherence to medications and help patients to regulate their routine activities, including going to bed, getting up, and exercising on a consistent schedule. We offer biofeedback for self-regulation, relaxation and coping skills training utilizing a cognitive behavioral model, and we treat psychiatric issues,” said Dr. Baskin. Many of those things can be done by clinicians who are not behavioral clinicians, he said. “You do not necessarily have to refer all these people. Schedule frequent revisits for complicated or difficult patients. Do not overwhelm patients with too much information. Simplify jargon, provide written instructions, and make sure the patient understands the plan.”

An important component of behavioral treatment is teaching relaxation exercises, which can reduce muscle tension and autonomic arousal. There are many types of relaxation strategies. Dr. Baskin recommended breathing pacer apps, which are designed to encourage slower abdominal breathing. The goal is to gradually reduce the breathing rate to six breaths per minute for five- to 10-minute practice sessions. “If you can teach people diaphragmatic breathing—it takes about 30 seconds to begin the discussion—it is helpful.” Dr. Baskin recommended having patients do it three to five times per day for a few minutes at a time.

“We deliver relaxation training alone, sometimes with biofeedback, and teach it as a self-regulation coping skill. We try to get people to develop an internal locus of control so they can manage some of their own physiology, relax muscles, and learn a nonspecific low-arousal response and use it as a coping skill to apply in different situations,” Dr. Baskin said.

Cognitive behavioral therapy is another tool. It gives people an opportunity to modify distress-related thoughts and to examine their personal danger cognitions, their sense of threat, and the negative predictions that they may have. Dr. Baskin uses cognitive behavioral therapy to help patients develop an action plan based on their prescribed strategy to treat an acute migraine attack as well as manage concomitant emotional reactivity and maintain functionality in the presence of a significant headache disorder.

Trigger Management

Historically, migraineurs have avoided headache triggers. The down side to that strategy is that they can unnecessarily restrict themselves. Studies suggest that avoiding triggers may lead to sensitization to those triggers. Gradual exposure coping models are being developed. “Cope, do not avoid,” Dr. Baskin said.

Biofeedback

Relaxation training, EMG biofeedback, thermal biofeedback, and cognitive behavioral therapy show grade A but modest efficacy. There is recent evidence that combining behavioral therapy with preventive pharmacologic treatment improves outcomes. The behavioral section of the American Headache Society will soon be reviewing the most recent evidence on behavioral interventions in migraine.

Sleep Hygiene

Three main messages regarding sleep are to adopt a routine, consistent bedtime and wake up time, avoid all non–sleep-related activities at bedtime, and employ relaxation strategies to reduce sleep onset latency. In addition, patients should not eat or drink a lot of fluid too close to bedtime, not exercise in the evening, and avoid napping. A patient should be advised that if he or she cannot sleep, the best solution is to get out of bed, go to another room in the house, engage in a relaxing activity, and go back to bed when he or she gets tired. With these strategies, clinicians have converted chronic migraine to episodic migraine for a significant number of patients.

Combination Treatment of Migraine and Psychiatric Disorder

Many doctors support the idea that one drug should treat migraine and associated conditions whenever possible. The idea is to use one agent to treat migraine and associated conditions (“two-fer”) This strategy is simpler and may entail lower cost, fewer adverse events, and fewer potential drug interactions. “It makes sense on one level, however, there’s a risk of treating only one condition optimally or treating none of them optimally,” Dr. Baskin said. “It is important to treat both disorders the way you think they should be treated. Sometimes two drugs are better than one. You want to treat both conditions effectively.”

When treating anxiety disorders with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), prescribers should know that people with anxiety are exceptionally sensitive to side effects. Also, anxiety disorders often require higher doses than treating depression. “You should start dosing incredibly low and titrate slowly,” Dr. Baskin said.

—Glenn S. Williams