Two-, three-, and four-year follow-up on the self-regulatory treatment of chronic headache

The Durability of Relaxation Training in Pediatric Headache Management

The long-term effects of relaxation training for pediatric headache disorders was determined for all four original participants from a multiple baseline across subjects design. Long-term follow-up data were collected at a mean of 81 months post-treatment.

All participants reported some increases in headache activity from 12-month to long-term follow-up, but at relatively low levels compared with baseline. Headache-free days were 51% to 86% fewer. Headache severity was 81% to 94% better, and headache duration was 75% to 94% better than baseline levels. Medication used was limited to over-the-counter analgesics on an as-needed basis for all subjects.

Three subjects (75%) stated that they would recommend relaxation training to other individuals experiencing headaches. The results of this study support the conclusion that relaxation training is an effective longterm treatment for migraine, tension, and mixed headache disorders originating in childhood or adolescence.

[Psychological therapy of migraine: systematic review]

This review summarizes the various forms of behavioral treatment of migraine which could demonstrate empirical efficacy. The main unimodal kinds of treatment are thermal and electromyography (EMG) biofeedback training and progressive muscle relaxation. The various relaxation techniques do not differ in their efficacy in treating migraine. On average a reduction in migraine frequency of 35-45 % is achieved. The mean effect sizes (ES) of various biofeedback techniques are between 0.4 and 0.6. Cognitive-behavioral treatment is applied as a multimodal treatment and on average achieves an improvement in migraine activity by 39 % and an ES of 0.54. All behavioral procedures can be used in combination or as an alternative to drug prophylaxis with comparable success. A combination of pharmacological and behavioral treatment can achieve additional success. There is strong evidence for the clinically significant efficacy of all forms of behavioral treatment in childhood and adolescence. There are no signs of differential indications.

Direct costs of preventive headache treatments: comparison of behavioral and pharmacologic approaches

OBJECTIVES

This study provides preliminary data and a framework to facilitate cost comparisons for pharmacologic vs behavioral approaches to headache prophylactic treatment.

BACKGROUND

There are few empirical demonstrations of cumulative costs for pharmacologic and behavioral headache treatments, and there are no direct comparisons of short- and long-range (5-year) costs for pharmacologic vs behavioral headache treatments.

METHODS

Two separate pilot surveys were distributed to a convenience sample of behavioral specialists and physicians identified from the membership of the American Headache Society. Costs of prototypical regimens for preventive pharmacologic treatment (PPT), clinic-based behavioral treatment (CBBT), minimal contact behavioral treatment (MCBT), and group behavioral treatment were assessed. Each survey addressed total cost accumulated during treatment (ie, intake, professional fees) excluding costs of acute medications. The total costs of preventive headache therapy by type of treatment were then evaluated and compared over time.

RESULTS

During the initial months of treatment, PPT with inexpensive mediations (<0.75 $/day) represents the least costly regimen and is comparable to MCBT in expense until 6 months. After 6 months, PPT is expected to become more costly, particularly when medication cost exceeds 0.75$ a day. When using an expensive medication (>3 $/day), preventive drug treatment becomes more expensive than CBBT after the first year. Long-term, and within year 1, MCBT was found to be the least costly approach to migraine prevention.

CONCLUSIONS

Through year 1 of treatment, inexpensive prophylactic medications (such as generically available beta-blocker or tricyclic antidepressant medications) and behavioral interventions utilizing limited delivery formats (MCBT) are the least costly of the empirically validated interventions. This analysis suggests that, relative to pharmacologic options, limited format behavioral interventions are cost-competitive in the early phases of treatment and become more cost-efficient as the years of treatment accrue.

Internet-based treatment of headache: does telephone contact add anything?

OBJECTIVE

To study the contribution of therapist-initiated telephone contact in the treatment of recurrent headache via the Internet.

BACKGROUND

Internet-based cognitive behavioral self-help is a promising new venue for the treatment of recurrent headache. While cost-effective, there are indications that this modality may be associated with high dropout rates.

DESIGN AND METHODS

The role of therapist-initiated contact was investigated in a randomized controlled trial in which 44 self-recruited headache sufferers were randomized to either a Web-based self-help program with e-mail support or to a group receiving, in addition, weekly individual telephone calls. An additional 8 control subjects were recruited to receive similar treatment outside of the study.

RESULTS

Dropout rates were 29% in the telephone support group and 35% in the control group, suggesting that the telephone calls did not affect dropout. Results showed significant reductions in headache-related disability, depression, maladaptive coping strategies, and perceived stress but little to indicate any superior performance in the Internet-only group and little improvement in the headache index. In short, therapist-initiated telephone calls did not influence the results.

CONCLUSIONS

Internet-based treatment for headache is not affected by minimal therapist-initiated telephone contact.

Psychological treatments for migraine

Psychological and behavioral treatments for migraine are described and evidence for their efficacy is reviewed. Treatments for children, adolescents, and the elderly, and for menstrual migraine are then discussed. Biofeedback, relaxation, and stress-coping treatments have all demonstrated effectiveness. These treatments are effective for the majority of migraine sufferers and treatment effects are reliably maintained for periods of at least one year. Little is known about the mechanism behind the efficacy of psychological treatments. Suggestions for future research on treatment mechanisms, enhancement of treatment effectiveness, and increasing the acceptance of psychological treatments are provided.

Long-term efficacy of combined relaxation: biofeedback treatments for chronic headache

Thirty-four patients having chronic idiopathic headaches participated in a long-term study comparing autogenic relaxation training alone (REL) with combinations of relaxation and electromyographic biofeedback (REL + EMG) or relaxation and temperature biofeedback (REL + TEMP). Assignment to treatment conditions was balanced on demographics and clinical characteristics, as well as headache classification according to muscle contraction or vascular headache symptomatology. The results indicate that REL + TEMP produced no additional improvements over REL following the 8-week treatment program, or at 6-month, or 12-month follow-up. However, REL + EMG produced significantly greater reductions in headache activity measures than the REL and REL + TEMP conditions at all post-treatment time points. Headache activity continued to improve over the follow-up period independent of treatment condition. These data indicate that EMG biofeedback augments long-term clinical improvements in headache patients who undergo autogenic relaxation training.

Long-term follow-up of migraine treatment: do the effects remain up to six years?

Fifty migraine subjects (constituting 79% of the originally treated sample) participated in a follow-up study to 6 yr after the end of treatment. Subjects had been treated with different forms of biofeedback methods (skin temperature, BVP of the temporal artery) and applied relaxation training. The assessment included 4 weeks of continuous self-monitoring of headache activity and medication usage, as well as a retrospective self-rating scale. The main results indicated that, on a group basis, headache reductions achieved at the end of treatment persisted for up to 6 yr, and were indeed enhanced during the follow-up period.

Comprehensive behavioral medicine in community mental health. A needs assessment that needs assessment

It is suggested that the massive costs incurred nationally in health care are in large part a fitting concern of Community Mental Health (CMH). There is considerable data available to suggest that as much as half of the variance in common health disorders is associated with behavioral factors. There is a rapidly growing movement to provide interventions geared toward these behavioral components in health disorders, but much of this has occurred outside of the traditional mental health environment. There are arguments to suggest that CMH should be more involved in the development of comprehensive behavioral medicine services, both in terms of the expertise and resources that it can bring to bear upon these problems, and its potential to reach segments of the population which are otherwise likely to be underserved, if served at all. Implications for CMH planning and financing are discussed, drawing upon a selective literature review and clinical illustrations.