Working With Headaches
Working With Headaches presents an example of Dr. Donald B. Penzien's multidisciplinary, cognitive–behavioral approach to treating clients who suffer from headaches. In addition to talking directly with the client, the approach emphasizes working closely with the client's physicians to make sure that the client receives the best medical treatment.
In this session, Dr. Penzien works with a 60 year-old African American woman who has suffered from headaches since she was 17. The session illustrates an initial evaluation, including gathering information about medication, stressors, and behavior that may affect the client.
This video illustrates part of the initial evaluation process to identify candidates for psychological and behavioral headache therapies. Rather than being open-ended, this assessment is highly focused on the presenting medical condition—recurrent headache—and potentially related factors. The assessment is designed to establish a headache diagnosis, to gather relevant headache history (including prior and present medical interventions), and to identify potential psychological and behavioral factors that may be pertinent to the patient's presenting complaint—information required by the psychologist to ascertain the patient's candidacy for behavioral intervention.
Headache is not a psychiatric disorder. Likewise, specific personality traits have not been identified that consistently characterize "headache sufferers" as a group or that predispose individuals to develop a headache syndrome. Furthermore, headache patients, by and large, present to physicians with a generally normal psychological adjustment. Thus, extensive psychological testing is probably unnecessary for the typical headache patient. Rather, a psychological screening is often sufficient to identify the subgroup of patients who require a more comprehensive psychological evaluation.
At initial evaluation, the clinician should address, at least in a cursory fashion, the headache patient's past and current level of psychosocial functioning. Psychosocial dimensions of interest are listed in Table 1.
|Table 1. Domains for Psychological and Behavioral Evaluation of Headache Patients|
|Psychological and Behavioral Domain||Relevant Clinical Features|
|Headache-related disability||Nature and degree of impairment in ongoing vocational and social activities secondary to headache|
|Psychiatric history||Psychological adjustment, preexisting psychological disorders, family history of medical and psychiatric illness, prior psychological therapy|
|Mental status examination||Mood and affect, accuracy of historical information, attitude, speech, thought disorder, cognitive processes, changes in vegetative functions, suicidal or homicidal ideation, intellectual level, insight and judgment|
|Behavioral observations||Pain-related behaviors, eccentricities of physical behavior, appearance, preoccupation with pain|
|Drug use||Analgesic medication, psychotropic medication, alcoholic beverages, recreational drugs|
|Environmental and lifestyle factors||Stress, coping skills, insufficient or excessive sleep, missing meals, dietary precipitants, environmental precipitants such as odors, heat, and noise|
|Family, social, and vocational factors||Family adjustment, familial pain models, reinforcement of pain behavior, current employment, litigation related to injury or disability|
Headache patients who are candidates for psychological–behavioral therapies also should undergo a careful work-up to establish their headache diagnosis and have had a recent medical examination.
Headache and Psychiatric Comorbidity
Patients with recurrent headache sometimes present with coexisting psychological disorders that merit professional intervention. Although most individuals with headache in the general population do not have comorbid psychiatric illness, many patients presenting to specialty clinics do—especially those with chronic daily headache or with medication-overuse headache.
Although recent epidemiological studies have identified a moderately strong association between migraine and mood disorders, the exact nature of the relationship remains unclear. It is unlikely that depression results simply as a consequence of the burden of living with a recurrent painful condition. Several epidemiological studies suggest the relationship is bidirectional with the presence of major depression or anxiety increasing the likelihood of subsequently developing migraine.
It is generally believed that the occurrence of comorbidity most likely arises from shared pathophysiology of migraine and mood disorders. In addition, personality disorders can seriously complicate headache evaluation and treatment and are not uncommonly identified among headache patients referred to psychologists by physicians. Careful psychological evaluation thus may be needed not only to determine whether significant psychopathology is present but also to obtain information about the relationship between psychological and headache disorders.
Trigger Factors for Headache
Failure to address triggering or exacerbating factors is cited as one of the most common reasons for the failure of headache treatment. General population studies indicate stress, sleep difficulties (e.g., irregular sleep and wake schedules, nonrefreshing sleep, insufficient sleep), fatigue, and lack of physical activity are the most frequently identified triggers for migraine and tension-type headache. There is, in fact, an important behavioral component to nearly all of the identified headache triggers (see Table 2).
|Table 2. Common Headache Trigger Factors|
|Disruption of dietary pattern or schedule||Fasting, insufficient food, delayed meals|
|Specific dietary agents||Caffeine, aged cheese, alcohol, chocolate, nuts, monosodium glutamate|
|Sleep||Excessive sleep, insufficient sleep, sleep schedule changes, sleep disorders (e.g., bruxism, sleep-related breathing disorders, restless legs, insomnia)|
|Ovarian hormones||Menstrual, oral contraceptives, pregnancy, menopausal|
|Environment||Heat, cold, air conditioning, sunlight, bright or flashing lights, computer screens, noise, smoke, odors, fumes|
|Physical exertion||Exercise, sexual activity|
|Breathing disorders||Sinusitis or allergies|
|Tobacco||Smoking, chewing, nicotine patch|
|Stressful events||During stress, after stress (i.e., let-down headache)|
|Negative emotional states||Anger, anxiety, crying, depression, worry|
|Postures||Poor ergonomic conditions (especially concerning the head and neck), restricted movements, bending, reaching, clenching, straining, rocking|
|Weather||Humidity, heat, barometric changes|
Thus, identification of headache triggers provides valuable opportunities for behavioral intervention and headache self-management. In behavioral headache self-management programs, patients prospectively monitor potential headache triggers. Once associations between their trigger factors and headache episodes are identified, patients develop (after initial instruction from the behavioral therapist) appropriate responses to avoid, modify, or cope more effectively with various triggers and in turn prevent or manage their headaches.
Behavioral Interventions for Recurrent Headache
Behavioral interventions are particularly well suited for migraine or tension-type headache patients who have any of the following conditions:
- a poor tolerance for pharmacological treatments
- medical contraindications
- an insufficient response to pharmacological treatments
- a patient preference for nonpharmacological treatment
- a pregnancy, a planned pregnancy, or nursing
- a history of frequent or excessive use of analgesic or other acute medications that can aggravate headache problems (or decrease responsiveness to other pharmacotherapies)
- significant stress or deficient stress-coping skills
The long-term goals of behavioral headache therapies include
- reduced frequency and severity of headache
- reduced headache-related disability
- reduced reliance on poorly tolerated or unwanted pharmacotherapies
- enhanced personal control of headache
- reduced headache-related distress and psychological symptoms
Over the past 3 decades, several behavioral interventions for headache (tension-type and migraine) have garnered ample empirical support. In most instances these interventions emphasize prevention of headache episodes as opposed to aborting an acute headache.
Although behavioral modalities can be highly effective as monotherapy, they are more commonly used in conjunction with pharmacological management. The well-validated behavioral interventions can be broadly categorized as:
- relaxation training
- biofeedback training
- cognitive-behavioral therapy (i.e., stress-management training)
- combinations of the above
Having been studied and employed extensively in the past 3 decades, these behavioral therapies are widely accepted as standard components of our treatment armamentarium for recurrent headache. Treatment gains with validated behavioral therapies are well maintained within the first year following treatment and may be maintained considerably longer without additional intervention. Comparisons between standard drug and psychological therapies for headaches generally have produced equivalent findings in nonselected headache patients, and there is some evidence that combining the two treatment strategies can yield incremental benefit over using either approach independently.
This video illustrates the psychological evaluation of patients with recurrent headache. It is most appropriately applied to patients with a diagnosis of migraine or tension-type headache and is an important step in determining such patients' candidacy for psychological and behavioral headache therapies.
Forms and Questionnaires
Donald B. Penzien, PhD, is a clinical psychologist who specializes in assessment and treatment of recurrent headache. He is particularly interested in headache diagnosis, behavioral headache therapies, and meta-analysis.
Dr. Penzien received his PhD from Ohio University in 1986, and after completing his internship at the Brown University Medical School, he joined the faculty of the University of Mississippi Medical Center (UMC) and founded the UMC Head Pain Center. He presently is professor of psychiatry and director of the Head Pain Center. He is a fellow of the American Headache Society and the Society of Behavioral Medicine.
Dr. Penzien has published extensively in the behavioral medicine arena, with over 100 research articles, book chapters, and monographs to his credit. He has received research grants from the National Institutes of Health and other agencies, including most recently, the American Headache Society. He serves as associate editor for the journal Headache, and he has served on the editorial boards of several other scientific journals.
He has served the American Headache Society on numerous committees, including its board of directors, education committee, and as chair of its electronic media committee. Dr. Penzien served as chair of the Nonpharmacologic Therapies Review Group for the Headache Treatment Guidelines Project funded by the Agency for Healthcare Research and Quality and of the Behavioral Clinical Trials Guidelines Workgroup.
He is also a member of the US Headache Treatment Guidelines Consortium. He also has provided service to the American Academy of Neurology, the American Council for Headache Education, the American Psychological Association, the Association for Behavioral and Cognitive Therapies, the Society of Behavioral Medicine, and the World Health Organization.
- Campbell, J. K., Penzien, D. B., Wall, E. M. (2000). Evidence-based guidelines for migraine headaches: Behavioral and physical treatments. Retrieved February 28, 2006, from http://www.aan.com/ professionals/practice/pdfs/gl0089.pdf
- Duckro, P. N., Richardson, W. D., & Marshall, J. E. (1995). Taking control of your headaches: How to get the treatment you need. New York: Guilford Press.
- Holroyd, K. A., Lipchik, G. L., & Penzien, D. B. (1998). Psychological management of recurrent headache disorders: Empirical basis for clinical practice. In K. S. Dobson & K. D. Craig (Eds.), Best practice: Developing and promoting empirically supported interventions (pp. 187–235). Newbury Park, CA: Sage.
- Holroyd, K. A., Penzien, D. B., & Lipchik, G. L. (2001). Behavioral management of headache. In S. D. Silberstein, R. B. Lipton, & D. J. Dalessio (Eds.), Wolff's headache and other head pain (7th ed., pp. 562–598). New York: Oxford University Press.
- Lake, A. E., Rains, J. C., Penzien, D. B., & Lipchik, G. L. (2005). Headache and psychiatric comorbidity: Historical context, clinical implications, and research relevance. Headache, 45, 493–506.
- McGrath, P. J., Penzien, D. B., & Rains, J. C. (2006). Psychological and behavioral treatments of migraine. In J. Olesen, P. Goadsby, N. Ramadan, P. Tfelt-Hansen, & K. M. A Welch (Eds.), The headaches (3rd ed., pp. 441–448). Philadelphia: Williams & Wilkins.
- Penzien, D. B., Andrasik, F., Freidenberg, B. M., Houle, T. T., Lake, A. E., III, Lipchik, G. L., et al., (2005). Guidelines for trials of behavioral treatments for recurrent headache. Headache, 45, S109–S131.
- Penzien, D. B., & Maizels, M. (Eds.). ( 2005 ). Headache research methodology [Special series]. Headache, 45, 408–537.
- Penzien, D. B., Peatfield, R. C. & Lipchik, G. L. (2006). Headache in patients with comorbid psychiatric disease. In J. Olesen, P. Goadsby, N. Ramadan, P. Tfelt-Hansen, & K. M. A Welch, The headaches (3rd ed., pp. 1117–1124). Philadelphia: Williams & Wilkins.
- Penzien, D. B., & Rains, J. C. (1995a). Self-Management Training Program for Chronic Headache: Patient manual. Sarasota, FL: Professional Resource Press.
- Penzien, D .B., & Rains, J. C. (1995b). Self-Management Training Program for Chronic Headache: Therapist manual. Sarasota, FL: Professional Resource Press.
- Penzien, D. B., Rains, J. C., Lipchik, G. L., & Creer, T. L. (2004). Behavioral interventions for tension-type headache: Overview of current therapies and recommendation for a self-management model for chronic headache. Current Pain and Headache Reports, 8, 489–499.
- Penzien, D. B., Rains, J. C., Lipchik, G. L., Nicholson, R. A., Lake, A. E., & Hursey, K. G. ( 2005 ). Future directions in behavioral headache research: Applications for an evolving healthcare environment.Headache, 45, 526–534.
- Rains, J. C., Penzien, D. B., McCrory, D. C. & Gray, R. N. (2005). Behavioral headache treatment: History, review of the empirical literature, and methodological critique.Headache, 45, S91–S108.
- Rapoport, A. M., Sheftell, F. D., & Tepper, S. J. (2004). Conquering headache (5th ed.). Hamilton, Ontario, Canada: BC Decker.
- Swanson, J. R. (2004). Mayo Clinic on headache. Rochester, MN: Mayo Clinic Health Information.
- American Council for Headache Education
- American Headache Society
- Behavioral Clinical Trials Guideline—Headache, journal supplement presenting guidelines for conducting clinical trials of behavioral therapies for headache (free download)
- HeadacheAndBehavior, an email list forum for professionals or students with interests in behavioral/psychological issues in headache
- International Headache Society
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