Cognitive Therapy and Relaxation Training in Muscle Contraction Headache: Efficacy and Cost-Effectiveness

SYNOPSIS
The purpose of this study was first, to examine the efficacy of adding a cognitive therapy component to traditional relaxation training; and second, to examine the feasibility and cost-effectiveness of administering these treatments in a largely self-ad-ministered format for headache patients. Twenty-five muscle contraction headache sufferers were assigned to one of three treatment conditions, which provided either relaxation training alone or relaxation training in combination with cognitive therapy. Procedures were delivered utilizing either a therapist-ad-ministered office-based format, or a largely self-administered format designed to provide significantly less therapist contact than the office-based procedure. At one-month post-treatment, patients in all 3 conditions exhibited significant decreases in headache activity, with no significant differences between the groups, although then appeared to be a slight advantage for the cognitive groups and for groups with increased therapist contact. Patients in all 3 groups evidenced significantly greater use of relaxation and cognitive strategies at post-treatment, with the combined treatment groups showing slightly greater use of the latter. Additionally, all 3 groups decreased their use of traditional medical strategies. There were no significant differences in cost-effectiveness among the 3 groups. However, overall this study suggests that largely self-administered treatments can result in significant improvements in headache, while substantially reducing the total amount of therapist contact.     

Effects of Voluntary Muscle Tension Increases in Tension Headache

SYNOPSIS
The relationship between hyperactivity of the head and neck muscles and the pain experienced in tension headache was assessed by comparing the subjective effects of voluntary frontal muscle contraction on self-reports of pain in chronic tension headache patients and in normal volunteers.
Ten tension headache patients and ten volunteers were taught to increase their frontal muscle tension over 10 μvolts through biofeedback and, on three occasions, were asked to maintain that level for periods of one, two or five minutes consecutively.
No difference in EMG levels were observed between patients and control either during baselines, contraction periods or subsequent resting phases. In contrast, headache patients reported more pain immediately and ten minutes after the contraction periods. The longer contraction periods were associated with higher pain intensity score, while the EMGs of the subsequent resting phases were lower. This occurred in both groups.
These results suggest that chronic tension headache patients are more prone to experience pain than normal volunteers with contraction of frontal muscles, in spite of the fact that EMG levels do not differ. A different pain threshold to muscle tension could be responsible for those differences.     

The Role of Stress in Recurrent Tension Headache

SYNOPSIS
This study investigated the role of stress in recurrent tension headache. Although recurrent tension headache sufferers (N=117) and matched headache-free controls (N=174) reported similar numbers and types of stressful life events, headache sufferers reported a greater number of chronic everyday stresses or daily hassles than did controls . Recurrent tension headache sufferers also appraised the stressful events they experienced more negatively than did controls, and employed less effective coping strategies in their efforts to manage stressful events. When the potential impact of a stressful event was ambiguous, recurrent headache sufferers appraised this event more negatively and themselves as having less control over the event than did headache-free controls. In their coping efforts, recurrent tension headache sufferers also placed greater reliance on the relatively ineffective coping strategies of avoidance and self-blame, and made less use of social support than did controls. These findings suggest that research on the role of stress in tension headaches should focus not on the occurrence of major stressful life events, but on the recurrent headache sufferer's cognitive appraisals of stressful events and efforts to cope with stress.     

Pain Response to Voluntary Muscle Tension Increases and Biofeedback Efficacy in Tension Headache

SYNOPSIS
The hypothesis that patients reporting an association between head pain and voluntary muscle tension increases could react more positively to EMG biofeedback was evaluated in 33 tension headache sufferers involved in a program of six training sessions and of a follow-up two months later. These patients were taught to increase their frontal muscle tension over 10 μvolts through biofeedback for a period of one minute at the first session and of two minutes at the second one. According to their subjective pain response, 14 patients were considered to show a positive association between head pain and muscle tension increases while the 19 others did not show such an association. The group of patients with a positive association between head pain and muscle tension showed a rapid symptomatic improvement which was partially lost as the training progressed, while the other reported a more linear gradual improvement. At follow-up, there was no difference in headache, drug usage and frontal EMG between the two groups. The differences in the shapes of the symptomatic responses are discussed in terms of patients' expectations from the training.     

Health Status in Patients with Tension Headache Treated with Acupuncture or Physiotherapy

Sixty-two female patients with chronic tension headache were randomly divided into two treatment groups--acupuncture and physiotherapy. Their overall function (Sickness Impact Profile), and mental well-being (Mood Adjective Check List) and the intensity and frequency of headache were assessed before and after treatment. Before treatment the patients showed significantly more dysfunction and less positive mental well-being than a general population sample. Both treatment groups improved in overall function, the physiotherapy group somewhat more. The mental well-being increased only in the physiotherapy group. The intensity and frequency of headache was significantly reduced in both the physiotherapy group and the acupuncture group. The intensity of headache was significantly more improved in the physiotherapy group. The improvement of headache intensity persisted unchanged 7-12 months after treatment.     

Follow-up on Behavioral Treatment of Recurrent Headache in Adolescents

A sample of 108 adolescent students suffering from migraine and tension headaches, treated with relaxation training and attention-control approaches, were evaluated at 5-6 month and 3-4 year follow-ups. Data were obtained for 69% (75) of the original subjects at the second follow-up. The treatments administered within a school setting were contrasted with students' self-monitoring of headache. The results indicated that students treated with relaxation training showed a good maintenance of posttreatment headache reduction at the two follow-up evaluations, 80% and 85%, respectively. Although treatment condition and level of pretreatment headache were associated with a favorable outcome at the 5-6 month follow-up, only baseline headache severity emerged as a significant predictor at the final follow-up. Several variables from the psychological functioning and health behavioral domains found to predict posttreatment outcome for the adolescent headache sufferers in previous research, did not contribute significantly to outcome at the follow-ups.     

Comprehensive Biofeedback Versus Self-Monitored Relaxation in the Treatment of Tension Headache

SYNOPSIS
Muscle contraction headaches have been demonstrated to significantly decrease following EMG biofeedback as well as general relaxation practice. This study contrasted the efficacy of a comprehensive biofeedback and stress management strategy and a self-monitored home relaxation program in the treatment of 20 tension headache sufferers. The results suggested that while both treatment strategies successfully increased patients' ability to relax and reduce frontalis EMG levels, only the comprehensive biofeedback program was successful in reducing reports of headache pain and feelings of psychological distress. The findings support the utility of a headache treatment model beginning with simple relaxation and progressing on a case by case basis to more comprehensive tension and stress management strategies (like EMG biofeedback and cognitive stress coping techniques) only when the less costly relaxation proves ineffective in altering subjective feelings of pain or distress.     

Relaxation Training in School Classes Does Not Reduce Headache Complaints

The effect of teacher-presented Progressive Relaxation Training (PRT) on headaches, fear of failure and school problems was studied in school students. During ten physical education lessons, students received either PRT (n = 110) or placebo training (n = 92). The effect of the training was investigated in students who indicated the presence of headaches in a pre-training diary. No significant differences were found between both training groups regarding headache frequency, duration and intensity and the psychological variables. On the basis of these and previous findings, it is recommended to present PRT to fairly small groups of self-selected subjects instead of complete classes.     

The Psychological Treatment of Recurrent Headache in Adolescents Short-Term Outcome and Its Prediction

SYNOPSIS
The results from three separate treatment studies on adolescents (N = 108) aged 16-18 years with predominantly recurrent tension (n = 85), and migraine (n = 23) headaches are presented along with information on predictors of short-term outcome. A standardized therapist-or home-based relaxation training program was compared to attention-control approaches in which information or problem-discussion procedures were provided for the students. These treatment conditions were both contrasted with self-monitoring procedures. All students were assessed and treated in a school setting and may therefore, be regarded as representing a nonclinical replication series. The outcome results indicated that the majority (53%) of students, in particular those with tension headache, had improved after both forms of relaxation training, which were clearly superior to attention-placebo control and self-monitoring contrasts. Furthermore, it was found that treatment condition, baseline headache severity and students' satisfaction with their home life were the strongest predictors of overall outcome, accounting for 32% of the total variance. For students provided with relaxation training, a set of four parameters, again including baseline headache severity, in addition to students' level of somatic symptoms, school satisfaction and disease within their family, emerged as strong predictors of outcome, explaining 44% of the outcome variance. The results are discussed in view of similar outcome and prediction studies in the field of pediatric and adult recurrent headache.     

Biofeedback and Relaxation Training: The Effect on Headache and Associated Symptoms

SYNOPSIS
Patients suffering with migraine and muscle contraction headaches were treated with EMG and thermal biofeedback and relaxation training. Three groups were formed: Patients whose last contact with the practice was 3–12, 13–24, or 25 or more months prior to the follow-up study. Each group included patients who never attended biofeedback, who attended one session, two to six sessions, or seven or more sessions of biofeedback. A telephone questionnaire revealed that 86% of patients who attended seven or more sessions of biofeedback maintained a 75–100% reduction in headache frequency through time (25 or more months). Of these patients, 65.5% reported a reduction in associated symptoms. Only 31% of patients who never attended biofeedback reported a reduction in headache frequency. Only 16.3% of patients who never attended biofeedback reported a reduction in associated symptoms. The combination of biofeedback and relaxation training clearly results in a reduction of both headache experience as well as in associated symptoms.     

The Significance of Muscle Discrimination Training in the Treatment of Chronic Muscle Contraction Headache

SYNOPSIS
The present study was undertaken to determine if chronic muscle contraction headache subjects who received training in muscle discrimination during a headache treatment program that included the standard application of behavioral procedures would be able to relieve muscle activity more effectively than those subjects who received only the conventional program. Thirty-eight subjects medically diagnosed as having muscle contraction headache were randomly assigned to one of the above treatment conditions or groups. Thirty subjects completed the ten-week study and treatment program. Stimulus discrimination training, consisting of exercises involving muscles of facial expression, EMG biofeedback and differential reinforcement, was employed. Results indicated that both groups markedly improved. Although the amount of change between the two groups was not statistically significant, the direction of change improved for the experimental group who received the increased, intensified muscle discrimination training. The findings suggest that clinicians who emphasize muscle discrimination training with this type of headache will most likely achieve better results in the way of treatment outcome than without that emphasis.     

Headache Diagnosis in Children and Adolescents

Purpose of Review

Headache phenotypes can differ between adults and children. While most headaches are due to primary headache disorders, in a small population, they can be an indication of a potentially life-threatening neurologic condition. The challenge lies in identifying warning signs that warrant further workup. This article reviews different types of pediatric headaches and headache evaluation in children and teens, and focuses on the approach for diagnosis of secondary headaches.

Recent Findings

Common thought is that increased frequency and severity of headache may reflect secondary pathology; however, headache phenotype may not be fully developed and can evolve in adolescence or adulthood. Headache location, particularly occipital headache alone, does not necessarily signify secondary intracranial pathology. Certain warning signs warrant neuroimaging, but others only warrant imaging in certain clinical contexts. Brain MRI is the neuroimaging modality of choice, though there is a high rate of incidental findings and often does not change headache management.

Summary

A stepwise approach is essential to avoid missing secondary headaches. There are several differences between adults and children in clinical manifestations of headache. Evaluation and diagnosis of pediatric headache starts with a thorough headache and medical history, family and social history, and identification of risk factors. A thorough physical and neurologic exam is important, with close attention to features that could suggest secondary headache pathology. Neuroimaging and other testing should only be performed if there is concern for secondary headache.

     

A Review of Studies Evaluating Biofeedback and Relaxation Training in the Management of Pediatric Headache

Headache is one of the most common types of recurrent pain among children. Response to pharmacological treatment has been inconsistent, and there is caution about prolonged pharmacotherapy for headache in children. Behavioral therapies for the management of chronic headache have emerged as a significant option over the last decade. Initial studies summarized in two previous reviews of behavioral therapy for pediatric headache were favorable, but few controlled studies had been done. In the last five years, more studies, the majority with controlled comparisons, have been published. The present review summarizes and interprets the evidence from these studies. Behavioral treatment appears to be a potent alternative for the management of chronic headache in children.     

Chronic Daily Headache in Children and Adolescents

Chronic daily headache (CDH) may be primary or secondary. Secondary causes can be suspected through “red flags” in the history and examination. With a prevalence of at least 1% and several associations, primary CDH is a common, often complex, chronic pain syndrome in children and adolescents. The intricate associations between stressors, psychiatric disorders (especially anxiety and depression), and CDH can be explained by “the limbically augmented pain syndrome” proposed by Rome and Rome. Disorders of sleep and other pain syndromes also may co-occur. For these reasons, a multiaxial classification is ideal. Many with primary CDH have features of both chronic migraine and chronic tension-type headache, contributing to confusion in subtyping. Primary CDH is often transformed from a primary episodic headache type, stressors being most responsible. Genetic factors also may facilitate chronification. Management should be biopsychosocial, family-centered, and often multidisciplinary, drugs being only one component. Treatment is still based on consensus, not evidence. Girls, migraineurs, and those with psychiatric comorbidity, medication overuse, and CDH onset before the age of 13 years and lasting for 2 years or longer, are at high risk for persistence; hence, such patients should be followed up into adult life. A classification for CDH should be included in the third edition of the International Classification of Headache Disorders.     

Chronic Daily Headache in Children and Adolescents

SYNOPSIS
Recurrent headache is a relatively frequent problem in children and adolescents, with the majority of the research attention focused on pediatric migraine. This study assessed differences in consequences to headaches, coping with headaches, and associated disability in children and adolescents attending a headache clinic who were diagnosed with migraine, chronic daily headache, or carried both diagnoses. Results, generally indicated higher levels of impairment for patient's with chronic daily headaches. These patients were also more likely to use blaming others and wishful thinking as coping mechanisms. Gender and racial status interacted with headache diagnosis to predict parent response patterns and disability outcomes. The results provide initial support for the applicability of Martin's functional model of chronic headaches to a pediatric population.     

Headache and Subacute Sinusiris in Children and Adolescents

SYNOPSIS
The medical records of 150 children and adolescents with chronic headaches seen during 1984 and 1985 were reviewed. Sinus pathology diagnosed radiographically was present in 15 patients. None had prominent respiratory symptoms. All improved with appropriate therapy directed toward the sinus pathology. The importance of including sinusitis in the differential diagnosis when seeing children and adolescents with chronic headache is emphasized.     

Personality Factors in Classical Migraine and Tension Headache

SYNOPSIS
The hypothesis that classical migraine and tension headache sufferers show a "specific headache personality" characterized by traits of obsessionality, neuroticism and repressed hostility was tested. A sample of fifteen classical migraine and fifteen tension headache sufferers selected without reference to treatment, was compared with fifteen non-headache normal subjects and fifteen subjects suffering physical pain but of a non-headache nature.
Personality tests of obsessionality, neuroticism, anxiety and hostility were administered. Analyses of variance revealed that sufferers from headache and non-headache physical pain had higher levels of neuroticism and repressed hostility than the non-headache controls. No evidence for increased incidence of obsessionality was found in any group.
It was concluded that the similarities between headache and non-headache physical pain sufferers found on several of the personality indices suggested that traits frequently reported as characteristic of headache sufferers may be the result of a coping strategy for recurrent pain and not specific to headaches.