Two studies of the long-term follow-up of minimal therapist contact treatments of vascular and tension headache

The Efficacy of Hypnotic and Nonhypnotic Response-Based Imagery for Self-Managing Recurrent Headache

Two experiments investigated the use of hypnotic and nonhypnotic response-based imagery training for recurrent headache. In Experiment 1, subjects with symptoms of chronic migraine headache (CMH), or chronic mixed migraine/tension headache (Mixed CMH/CTH) were assigned to a Hypnotic or Nonhypnotic Imagery group, or to a Monitoring Control group. Treatment efficacy was assessed over two-week intervals, at Baseline, Post-treatment, and three successive follow-up periods. In Experiment 2, subjects with symptoms of chronic tension headache (CTH) were assigned to four conditions (Hypnotic Imagery/Nonhypnotic Imagery/Placebo/Monitoring Control), and studied across two-week intervals at Baseline, Post-treatment, and eight-week Follow-up. Hypnotic and Nonhypnotic Imagery conditions did not differ in demonstrating efficacy in reducing headache activity in both experiments. Treatment outcome was not associated with medication consumption, or actual changes in physiologic processes (cardiovascular functioning and frontalis EMG). Headache reduction was not correlated with hypnotizability or the trait propensity to engage in vivid imagery. These results replicate and extend previous findings, and support the use of imagery strategies as a treatment component in pain management programs.

Behavioral treatment of headaches: extending the reach

Behavioral treatments (predominantly biofeedback, relaxation, and cognitive-behavioral) have been utilized in headache management for many decades. Although effective, they have not been as widely implemented as desired, chiefly due to their time-intensive nature, special therapist qualifications, and patient costs. This paper focuses on ways to make these treatments more affordable and more readily accessible to patients. Various alternative delivery models have been explored. This paper reviews progress to date on three such approaches for treating recurrent headaches in adults--prudent limited office contact, Internet delivery, and mass media approaches. Clinical outcomes, advantages, and disadvantages of these approaches are reviewed in brief.

Psychiatric comorbidity and response to preventative therapy in the treatment of severe migraine trial

INTRODUCTION

Mood and anxiety disorders are comorbid with migraine and commonly assumed to portend a poor response to preventive migraine therapies. However, there is little evidence to support this assumption.

METHOD

We examined impact of a mood and/or anxiety disorder diagnosis using American Psychiatric Association Diagnostic and Statistical Manual criteria on response to the three preventative migraine therapies evaluated in the Treatment of Severe Migraine trial (n = 177): β-blocker, behavioral migraine management, or behavioral migraine management +β-blocker. Daily diaries assessed migraine activity for the 16 months of the trial. The Migraine Specific Quality of Life Questionnaire and Headache Disability Inventory assessed headache-related disability at regular intervals. Mixed models for repeated measures examined changes in these three outcomes with preventative migraine therapy in participants with and without a mood or anxiety disorder diagnosis.

RESULTS

Participants with a comorbid mood or anxiety disorder diagnosis recorded larger reductions in migraine days (p < .05) and larger reductions in the Migraine Specific Quality of Life Questionnaire (p < .001) and Headache Disability Inventory (p < .01) than did participants with neither diagnosis.

DISCUSSION

Significantly larger reductions in migraine activity and migraine-related disability were observed in participants with a mood and/or anxiety disorder diagnosis than in participants who did not receive either diagnosis.

Behavioral treatments of chronic tension-type headache in adults: are they beneficial?

To assess the efficacy of behavioral treatments in patients with tension headache. Medline, Cinahl, EMBASE, and the Cochrane library were searched from inception to October 2007 and reference lists were checked. We selected randomized trials evaluating behavioral treatments (e.g., relaxation, electromyographic [EMG] biofeedback, and cognitive behavioral training) in patients with tension-type headache (TTH). We assessed the risk of bias using the Delphi list and extracted data from the original reports. A qualitative analysis was carried out. We found 44 trials (2618 patients), which were included in this review, of which only 5 studies (11.4%) were considered to have low risk of bias. Most trials lacked adequate power to show statistical significant differences, but frequently, recovery/improvement rates did not reach clinical relevance. In 8 studies, relaxation treatment was compared with waiting list conditions, and in 11 studies, biofeedback was compared with waiting list conditions, both showing inconsistent results. On the basis of the available literature, we found no indications that relaxation, EMG biofeedback, or cognitive behavioral treatment is better than no treatment, waiting list, or placebo controls.

Tension-type headache: current research and clinical management

Tension-type headache (TTH) is the most common form of headache, and chronic tension-type headache (CTTH) is one of the most neglected and difficult types of headache to treat. The pathogenesis of TTH is multifactorial and varies between forms and individuals. Peripheral mechanisms (myofascial nociception) and central mechanisms (sensitisation and inadequate endogenous pain control) are intermingled: the former predominate in infrequent and frequent TTH, whereas the latter predominate in CTTH. Acute therapy is effective for episodes of TTH, whereas preventive treatment--which is indicated for frequent and chronic TTH--is, on average, not effective. For most patients with CTTH, the combination of drug therapies and non-drug therapies (such as relaxation and stress management techniques or physical therapies) is recommended. There is clearly an urgent need to improve the management of patients who are disabled by headache. This Review summarises the present knowledge on TTH and discusses some of its more problematic features.

Cognitive-Behavioral self-help for chronic pain

Cognitive behavioral self-help is a potentially cost-saving method of delivering evidence-based treatment to a wide range of chronic pain patients. This article provides a rationale for self-help and focuses on the effectiveness of self-help in the management of chronic pain, which typically includes some degree of lay leader or professional facilitation. The evidence for these treatments is generally positive (e.g., reductions in pain and pain-related disability) across such illnesses as arthritis, back pain, headache, and temporomandibular joint disorders. When implementing self-help, professionals need to consider individual differences in suitability for using a self-management treatment and evaluate the outcome in the context of a stepped care approach. This article uses three case examples to illustrate the use of cognitive behavioral self-help delivered in the care of scleroderma patients.

A randomized controlled trial of an internet-based treatment for chronic headache

Chronic headache is a significant public health problem in Western nations. Although controlled trials demonstrate the efficacy and cost-effectiveness of face-to-face behavioral therapy, most headache sufferers have limited access to these treatments. Delivery of behavioral interventions using Internet technology has the potential to reach a larger number of headache sufferers and reduce the burden of disease. This randomized controlled study evaluated an Internet-delivered behavioral regimen composed of progressive relaxation, limited biofeedback with autogenic training, and stress management versus a symptom monitoring waitlist control. Treatment led to a significantly greater decrease in headache activity than symptom monitoring alone. Thirty-nine percent of treated individuals showed clinically significant improvement on self-report measures of headache symptoms at post-treatment. At two-month follow-up, 47% of participants maintained improvement. Treatment had a significant impact on general headache symptoms and headache-related disability. There was a 35% within-group reduction of medication usage among the treated subjects. The Internet program was more time-efficient than traditional clinical treatment. Treatment and follow-up dropout rates, 38.1% and 64.8%, respectively, were typical of behavioral self-help studies. This approach to self-management of headache is promising; however, several methodological and ethical challenges need to be addressed.

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.

Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial

CONTEXT

Chronic tension-type headaches are characterized by near-daily headaches and often are difficult to manage in primary practice. Behavioral and pharmacological therapies each appear modestly effective, but data are lacking on their separate and combined effects.

OBJECTIVE

To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for chronic tension-type headaches.

DESIGN AND SETTING

Randomized placebo-controlled trial conducted from August 1995 to January 1998 at 2 outpatient sites in Ohio.

PARTICIPANTS

Two hundred three adults (mean age, 37 years; 76% women) with diagnosis of chronic tension-type headaches (mean, 26 headache d/mo).

INTERVENTIONS

Participants were randomly assigned to receive tricyclic antidepressant (amitriptyline hydrochloride, up to 100 mg/d, or nortriptyline hydrochloride, up to 75 mg/d) medication (n = 53), placebo (n = 48), stress management (eg, relaxation, cognitive coping) therapy (3 sessions and 2 telephone contacts) plus placebo (n = 49), or stress management therapy plus antidepressant medication (n = 53).

MAIN OUTCOME MEASURES

Monthly headache index scores calculated as the mean of pain ratings (0-10 scale) recorded by participants in a daily diary 4 times per day; number of days per month with at least moderate pain (pain rating >/=5), analgesic medication use, and Headache Disability Inventory scores, compared by intervention group.

RESULTS

Tricyclic antidepressant medication and stress management therapy each produced larger reductions in headache activity, analgesic medication use, and headache-related disability than placebo, but antidepressant medication yielded more rapid improvements in headache activity. Combined therapy was more likely to produce clinically significant (>/=50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants; P =.006), stress management therapy (35%; P =.003), or placebo (29%; P =.001). On other measures the combined therapy and its 2 component therapies produced similar outcomes.

CONCLUSIONS

Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy.

Brief cognitive-behavioral group treatment for children's headache

OBJECTIVE AND DESIGN

Using a randomized design with a waiting list control condition, we assessed the effectiveness of an abbreviated cognitive therapy group program for headaches in children 7 to 12 years of age. In the treatment condition, small groups of five to eight children were taught relaxation, distraction, visualization, and stress management skills in two 90-minute sessions. Parent groups, seen concurrently, reviewed the children's program and addressed parenting strategies. The waiting list control groups were treated 5 weeks later. Thirty-six children meeting inclusion criteria were included in the study; complete data were available for 29 participants (mean age, 9.4 years; 66% female).

DEPENDENT MEASURES

We obtained children's ratings of headache frequency, intensity, duration, and five other variables in a diary kept for 3 weeks before and 3 weeks after treatment. Parent measures were collected once before treatment and once at 3-month follow-up.

RESULTS

CHILD RATINGS: The control condition showed a significant reduction in children's self-rated headache frequency, while the treatment condition did not. On all other self-reported variables, there were no significant differences between the control and treatment conditions. Two participants in each condition achieved a 50% or greater reduction in a self-rating headache index.

RESULTS

PARENT RATINGS: Follow-up ratings, obtained over the telephone from parents after the children in both conditions had been treated, indicated that the children in both conditions had experienced reduced intensity, frequency, and duration of headaches and that 82% of the children were using the techniques taught in the program. Fourteen children achieved a 50% or greater reduction in a headache index based on parent ratings.

CONCLUSIONS

Although parents were very positive about the effectiveness of the program, the results for children's self-ratings do not support the use of this highly abbreviated treatment method.

Behavioral management of migraine

Behavioral treatments for migraine have received increased attention over the past 25 years. In general, research has focussed on the six following areas: 1) comparative efficacy of treatments, 2) interplay of behavioral and pharmacological approaches, 3) development of delivery models that are cost-effective, 4) identification of characteristics associated with varied levels of response to treatment, 5) maintenance of effects and factors associated with long-term outcome, and 6) mechanisms of treatment. This paper briefly and selectively reviews the available literature in an attempt to point out the status of current research.

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.

To soothe the savage breast

We review quite a range of procedures--some strange, some familiar--to calm, and spare fantasied harm. Drugs can help a whole bunch, but there is no 'free lunch.' Side-effects from long use, and the risk of abuse, make it wiser to find other means to 'unwind.' (Anxious folks spin a messful of thoughts that are stressful.) Against pressures that fluster, tranquil images muster a sense one is resting--rather than testing how much one achieves (while one's family grieves). Muscle programs to lower tense states, and pace slower, can bring manifold gains easing worry and pains. There are diverse connections among muscle flexions--however those function--that can serve as an unction. Movements practiced each night do more good than the 'right' exercises in theory, left undone by the weary. Thus give choice of routines as well as calm scenes: one might dodge heart attacks if one learns to relax. It will not cheer one's mood to review woes nor brood over future collusions, intrusions, confusions, perfection, rejection and other delusions. Like over-tight shoe points, loosen Puritan viewpoints because standards too stern make adrenaline burn. Teach instead: 'Mellow visions need not earn derisions. People who play more are invited to stay more.' Massages and dancing, gentle fiction entrancing or dulcet harmonics are suitable tonics. For self-damaging actions bring on wholesome distractions. There are so many names for so many games, from social adventures to buying debentures, trip-planning, food-canning and even gold-panning. Thus cease surplus panting but cultivate planting since turmoil may go when one makes flowers grow, or elsewhere embraces Nature's several faces: oceans, rivers, or canyons, mountains, redwoods or banyans, or (thanks to some vets), peaceful contacts with pets.

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.

Treatment integrity of relaxation training for tension headaches

Treatment integrity procedures, generally lacking in previous research, were employed for evaluation of relaxation training for tension headaches. Treatment integrity is the extent to which the therapist implements the relaxation procedure as described, and the degree to which the patients comply with the therapist's instructions. Objective compliance with the home practice of relaxation training was assessed using a microcomputer-based method which required the patient to squeeze a hand control when instructed to tense a muscle. A single-case replication design with three tension headache patients was used. The dependent variables were taken from patients' self-reported daily headache data. Results indicate that: (a) the therapist accurately adhered to the relaxation training protocol; (b) headache frequency decreased in all patients from baseline to 1-year follow-up (improvements ranged from 72.7% to 98.2%); and (c) improvement was greater with higher compliance.

Two controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome

We report two controlled comparisons of a previously validated multicomponent (relaxation, thermal biofeedback, and cognitive therapy) treatment for irritable bowel syndrome (IBS) to an ostensible attention-placebo control (pseudo-meditation and EEG alpha suppression biofeedback) and to a symptom-monitoring control. In Study 1 (n = 10 per condition) there were nonsignificant trends for the multicomponent treatment to be superior to the attention-placebo condition. In Study 2 (n = 30 per condition), we found no advantage for the multicomponent treatment over the attention-placebo condition. Subjects in both treatment conditions showed significant reductions in GI symptoms, as measured by daily symptom diaries, and significant reductions in trait anxiety and depression. The GI symptom reductions held up over a 6 month follow-up. Possible explanations for the results are explored.