1. BEHAVIORAL MIGRAINE MANAGEMENT Kenneth A. Holroyd, Ph.D. Ohio University

2. Behavioral Treatments Relaxation Therapy Biofeedback Therapy Cognitive-Behavior (Stress-Management) Therapies Combinations of the above treatments

3. Relaxation Training Relaxation Training Types of Relaxation Training –Progressive muscle relaxation –Autogenic training –Meditation or passive relaxation

4. ...I’m telling you, Ed. You’ve got to learn to deal with tension better

5. Relaxation Training Relaxation training involves a specific set of procedures not just “trying to relax” –Individuals adapt to chronic muscle tension May not recognize tension or relaxation May not know how to relax –Progressive muscle relaxation procedure Begins with tensing & relaxing 12 muscle groups (25 min) Proceeds in steps to quick cue controlled relaxation that can be used throughout the day –Goals of relaxation training include Increase awareness of early signs of headache onset Use relaxation to prevent and abort headaches Increase personal sense of control (self-efficacy)

6. Biofeedback Training Biofeedback Training Monitor headache-related physiological responses Present information (“feedback”) about physiological response (e.g., audio tone) Patient uses “feedback” to learn to regulate the response

7. Biofeedback Training

8. Types of Biofeedback Training Electromyographic (EMG) Biofeedback –Typically for tension-type headache Thermal (“hand-warming’) biofeedback –Typically for migraine Other –Cephalic vasomotor biofeedback –GSR feedback, Neurofeedback (EEG)

9. Biofeedback Training EMG Biofeedback –May be effective in in individuals who are unable to master relaxation training –May enable deeper muscle relaxation than relaxation training –May be accepted by patients who are averse to psychological treatment Thermal Biofeedback –Hand-warming may require weeks of practice to learn –Hand-warming response is used primarily to prevent, but also to abort migraines

10. Cognitive-Behavioral Stress- Management Therapy Teach patients to: – Identify & manage stress-generating thoughts & beliefs Prevent stress-related headaches Manage pain, distress & disability when headaches occur. Manage psychological consequences (e.g., depression, helplessness) of headaches

11. Cognitive-Behavioral Stress- Management Therapy Cognitive-Behavioral Stress- Management Therapy Thought Monitoring: –Identify stress-generating thoughts & “underlying” beliefs Skills training: –Teach cognitive (e.g., self-talk) and behavioral (e.g., ) coping skills Application: –Apply skills in progressively more challenging situations.

12. Cognitive-Behavioral Stress- Management Therapy Stress-Generating Thoughts –Catastrophizing I wonder whether something serious may happen I keep thinking how much it hurts Stress- Generating Beliefs –Expecting Perfectionism –Expecting Approval Holroyd et al., 2005

13. Cognitive-Behavioral Stress- Management Therapy Stress-Generating Thoughts –Recognizing & challenging thoughts – Coping “Self-Talk” Stress-Generating Beliefs –Reversing Positions –Reframing –Reality Testing

14. Management of Migraine in Primary Care Settings Evidence-Based Treatment Guideline American Academy of Family Physicians American Academy of Neurology American Headache Society American College of Emergency Physicians American College of Physicians American Osteopathic Association National Headache Foundation Diagnostic and Neuroimaging Acute Treatment Preventive Treatment Behavioral and Physical Treatment U.S. Headache Treatment Guideline Consortium Member Organizations Guideline Components

15. Literature on Behavioral Treatments 355 articles identified 70 controlled trials identified 39 prospective, randomized, controlled trials aimed at prevention of migraine attacks met all data extraction requirements

16. Statistical Analysis “Effect Size” (each treatment comparison) = standardized difference between group means “Percentage Improvement” = [pre-tx - post-tx/pre-tx score] X 100 Summary Statistics: –summary ES using random effects model –avg. % improvement weighted by sample size

18. Meta-Analysis of Behavioral vs. Pharmacologic Treatment of Migraine (% change)

19. Specific Treatment Recommendations Findings: RLX, BF, and CBT are all somewhat effective in preventing migraine when compared with controls. Recommendation RLX, BF, and CBT may be considered as treatment options for prevention of migraine (Grade A Evidence)

20. Specific Treatment Recommendations Findings: Behavioral treatments have been directly compared and combined with drug treatments for migraine. Propranolol conferred additional benefits when added BF, and CBT. Recommendation Behavioral therapy may be combined with preventive drug therapy to achieve additional clinical improvement (Grade B Evidence)

21. Meta-analysis of Pediatric Migraine Treatments Herman, Kim & Blanchard, 1995

22. Pediatric Migraine Readily learn control of physiological response High response rate to behavioral interventions Game-like task involves child Skills can be used into adulthood Limited drug options

23. Telephone Administered Behavioral Treatment % Exhibit Headache Management Skills in Clinic –100% ≥ 1 skill –67% ≥ 2 skills –27% ≥ 3 skills Relaxation, partial relaxation, diaphragmatic breathing, thermal biofeedback McGrath et al. (1992)Corrtell et al., in preparation

24. Behavioral Migraine Management Overview  Basic Migraine Management Skills  Relaxation Skills  Identifying & Managing Migraine Triggers  Recognizing & Responding to early Warning Signs  Effectively Using & Evaluating Migraine Medications  Coping with Migraines

25. Behavioral Migraine Management Advanced Migraine Management Skills A. Hand-warming Learning hand-warming Applying hand-warming to prevent migraines or B. Stress Management Identifying & challenging stress- generating thoughts Identifying & challenging stress-generating beliefs Applying stress-management skills

26. Headache Locus of Control Health Professionals Scale –Only my doctor can give me ways to prevent headaches –If I don’t have the right medication, my headaches will be a problem –My headaches can be less severe if medical professionals take proper care of me

27. Headache Locus of Control Internal Locus of Control –I can prevent some of my headaches by avoiding certain stressful situations –My headaches are sometimes worse because I am overactive –If I can remember to relax I can avoid some of my headaches

28. Self-Efficacy Beliefs Self-Efficacy Beliefs Self-Efficacy = Confidence that one can perform headache management activities Self-efficacy: – Is assessed for a specific domain – Is assessed with reference to specific behaviors – Is highly malleable

29. Headache Self-Efficacy Scale Headache Prevention: – I can prevent some of my headaches by recognizing headache triggers Disability Management: – I can can keep a mild headache from disrupting my day by changing the way I respond to pain

30. TCTH TRIAL: INITIAL TREATMENT PHASE AM + Clinical Management Placebo + Clinical Management SMT+ Placebo Baseline Reevaluation SMT + AM 4 weeks 12 weeks 4 weeks

31. SAMPLE CHARACTERISTICS (N = 203) Diagnosis: All patients IHS 2. 2 CTH; 25% co-morbid migraine diagnosis; IHS 8.2 excluded Gender: 77% female Age: M = 37.0 years Race: 95% Caucasian Frequency : M = 26.0 headache days/ month Chronicity: M = 12.5 years problem headaches

37. Conclusions Behavioral Migraine Management (BMM) –Combines behavioral interventions in an integrated treatment package –BMM can improve migraines and quality of life –BMM can help empower patients to be actively involved in the management of their migraines –BMM is a promising intervention for the management of migraines in adolescents Telephone administration may make BMM more accessible to adolescents