STOWE, VT—Engage the patient in the treatment process, educate regarding this process, evaluate the patient’s needs and concerns, eliminate offending agents, enact pharmacologic and behavioral treatment, and establish a long-term treatment plan. Those are the six key components of effective behavioral treatment of headache, according to a report presented at the Headache Cooperative of New England’s 16th Annual Headache Symposium.

The goals of behavioral treatment are to reduce the frequency and severity of the pain," said Randall E. Weeks, PhD, Codirector of the New England Institute for Behavioral Medicine, Stamford, Connecticut. This includes embracing a biobehavioral model of chronic headache, instead of adhering to an organic/psychogenic distinction. Specific approaches focus on reducing reliance on poorly tolerated, overused, or unwanted medications; reducing headache-related distress; and treating comorbid psychological symptoms. "Behavioral treatments, in fact, do work," said Dr. Weeks. "They are also very effective in augmenting pharmacologic therapy."

According to the US Headache Consortium Guidelines for Nonpharmacological Treatment, patients for whom behavioral treatment (such as relaxation training, thermal biofeedback with relaxation training, EMG biofeedback, and cognitive behavioral therapy) may be indicated include those who prefer such therapy; those with poor response, tolerance, or medical contraindications to specific pharmacologic treatment; those who are pregnant, plan to become pregnant, or are breast-feeding; those with a history of long-term, frequent, or excessive use of analgesic or acute medications; and those who have significant stress or deficient coping skills.

"Unfortunately, we see a lot of kids [with headache who] haven’t gone to school for years," he said. "The physicians with whom I work would prefer not to medicate children on a daily basis—a conservative medical approach. If they do medicate, they start at a low dose but increase the dose to an appropriate therapeutic level to maximize the chance that the medication will work. This is an aggressive approach, as many physicians will treat their young patients with subtherapeutic doses, which minimizes the likelihood of efficacy. Again, we would prefer not to medicate these patients on a daily basis, but if a pharmacologic treatment is used, it should be instituted cautiously but at appropriate therapeutic levels, and we insist that they get involved in behavioral treatment, because that’s usually a big part of the story."

To engage a patient in treatment, "the patient’s got to buy into it," Dr. Weeks said. Studies have shown that up to 40% of patients never return for a second visit. Some patients have inappropriate expectations of headache therapies, in that they are looking for a "magic pill"; others are angry because past treatments have failed, often because of underdosing or because patients did not give the treatment a chance to work.

"You want to try to position treatment as a collaborative effort—an effort between you and the person you’re working with—simply because you cannot take the onus and responsibility for getting your patients better; they have to be a part of it. Frequent contact may be needed," he added, as are explanations of the pharmacologic and behavioral treatments that will be offered, and emphasis on compliance.

Education includes discussing what people believe triggers their headaches and how disabling they are. "It’s really important to understand what the patients know," he said. "What do they want to get out of treatment? And have they understood previous therapy rationales? How do they feel about not medicating every day or about changing medications? Are patients medicating underlying affective issues?" Headache calendars are important when patients are undergoing detoxification, as is limiting the number of pain prescriptions. Treatment options include reinitiating failed treatments, especially if headache occurred due to medication overuse. "It’s always important to ask, When does the patient medicate?" he said, noting that for some patients, it’s on a time-contingent basis—for example, two aspirin every morning.

"We want to decrease sick-role and pain behavior and try to get patients out of being patients and back to being people," he said. "When someone walks up to them, the first thing they say isn’t, ‘How bad’s your headache today?’—they say, ‘What are you doing today?’ That’s an important paradigm shift for many of these people."

"We want patients to be active participants, to take personal responsibility for their pain. It is amazing, the indifference that patients have to their pain, to their disability in life," he said. For that reason, he recommends developing pain management action plans. "You don’t want patients to be helpless when the pain starts," he said. "You want them to have a strategy." Nonpharmacologic treatment can include changes in diet, consistency in sleep, an increase in pleasurable activities, and exercise, as well as introduction of specific strategies such as biofeedback, yoga, and acupuncture.

In establishing a long-term treatment plan, "I absolutely believe migraine headache is managed, not cured," Dr. Weeks said. "I tell patients, ‘I hope you never get another one, but you might.’" Periodic follow-up with patients with a history of complicated headache or medication overuse may help with compliance. It is also "important to talk to people about how long it may take before you expect them to get better. And finally, sometimes you’ve got to wave the white flag and send people to a tertiary care center or headache clinic," he concluded.

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