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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
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.
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).
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:
The long-term goals of behavioral headache therapies include
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:
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 Daily Headache Self-Monitoring Form (PDF: 39KB) |
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