Behavioral Headache Treatment: History, Review of the Empirical Literature, and Methodological Critique

Theoretical developments and burgeoning research on stress and illness in the mid-20th century yielded the foundations necessary to conceptualize headache as a psychophysiological disorder and eventually to develop and apply contemporary behavioral headache treatments. Over the past three decades, these behavioral headache treatments (relaxation training, biofeedback, cognitive-behavioral therapy, and stress-management training) have amassed a sizeable evidence base. Meta-analytic reviews of the literature consistently have shown behavioral interventions to yield 35% to 55% improvements in migraine and tension-type headache and that these outcomes are significantly superior to control conditions. The strength of the evidence has lead many professional practice organizations to recommend use of behavioral headache treatments alongside pharmacologic treatments for primary headache. The present overview was prepared as a companion article to and intended to provide a background for the Guidelines for Trials of Behavioral Treatments for Recurrent Headache also published within this journal supplement. This article begins with a synopsis of key historical developments leading to our current conceptualization of migraine and tension-type headache as psychophysiological disorders amenable to behavioral intervention. The evolution of the behavioral headache literature is discussed, exemplified by publication trends in the journal Headache . Leading empirically-based behavioral headache interventions are described, and meta-analytic reviews examining the migraine and tension-type headache literatures are summarized, compared, and contrasted. A critique of the methodological quality of the clinical trials literature is presented, highlighting the strengths and weaknesses in relation to recruitment and selection of patients, sample size and statistical power, the use of a credible control, and the reproducibility of the study interventions in clinical practice.     

Behavioral Facilitation of Medical Treatment of Headache: Implications of Noncompliance and Strategies for Improving Adherence

Clinical recommendations were gleaned from a review of treatment adherence published in the regular issue of Headache (released in tandem with this supplement). The recommendations include: (1) Nonadherence is prevalent among headache patients, undermines treatment efficacy, and should be considered as a treatment variable; (2) Calling patients to remind them of appointments and recalling those who miss a scheduled appointment are fundamentally the most cost-effective adherence-enhancing strategies, insofar as failed appointment-keeping acts as a ceiling on all future treatment and adherence efforts; (3) Simplified and tailored medication regimens improve adherence (eg, minimized number of medications and dosings, fixed-dose combinations, cue-dose training, stimulus control); (4) Screening and management of psychiatric comorbidities, especially depression and anxiety, is encouraged; (5) The concept of self-efficacy as a modifiable psychological process often can be employed to predict and improve adherence.     

Effects of a Mass Media Behavioral Treatment for Chronic Headache: A Pilot Study

This article presents the results of a pilot study evaluating the efficacy of a mass media self-help behavioral treatment program for chronic headache.
The program consisted of a self-help textbook, an exercise book, 10 television programs, 11 radio programs, and 3 audiocassettes with relaxation training. Approximately 15000 headache sufferers purchased the book and relaxation tapes. A random sample of 271 respondents participated in the effect study; the pretraining and posttraining data of 164 subjects were available for analysis.
Multivariate testing of the pretraining and posttraining results showed highly significant reductions in headache activity and medication intake at 4-month follow-up. A reduction of 50% or more in headache parameters and medication intake was achieved by 40% to 60% of the patients. Work absenteeism was significantly reduced. The differences between the diagnostic groups were not significant. Mass media behavioral treatment seems to be a viable treatment alternative for chronic headache and highly promising in terms of gain in quality of life, decrease in economic loss, and cost-effectiveness in health care.     

Design of Control-Group Conditions in Clinical Trials of Behavioral Interventions

PURPOSE: To review considerations in the design of placebo (attention) control conditions for community-based clinical trials of health behavior change interventions and to provide practical strategies for the design of control conditions. ORGANIZING CONSTRUCTS: A well-designed control condition is an essential component of a clinical trial to foster the unambiguous interpretation of study findings. METHODS: Pitfalls in the design of control conditions in clinical trials of behavioral interventions are identified and strategies to address them are offered. Types of control conditions that have been used in fall prevention trials are described, along with their strengths and weaknesses. The control condition used in the recent fall evaluation and prevention program (FEPP) was designed to overcome limitations of previous trial designs; it is provided to illustrate how to apply specific design principles. CONCLUSIONS: Pitfalls in the design of behavioral intervention studies may be avoided with the application of sound design principles. The FEPP active control condition can be used as a model in the design of future studies.