Behavioural Treatments for Migraine

Introduction

According to Wikipedia - Behavioural Medicine is an interdisciplinary field combining both medicine and psychology and it is concerned with the integration of knowledge in the biological, behavioural, psychological, and social sciences relevant to health and illness. Migraine commonly first occurs during adolescence or early adulthood. By encouraging patients to train their physiology through biofeedback and relaxation, adopt healthy lifestyle habits, and recognize and manage the effects of stress in their lives, physician’s are giving patients a set of tools that can last a lifetime. Behavioural techniques have also been a proven treatment for children and adolescents with headaches. Behavioural Treatments are a very effective way to reduce and sometimes control the symptoms of pain that migraine sufferers experience. Physicians often recommend them as a way to reduce the symptoms of migraine (pain, nausea, etc.). First-noted are reasons why a physician might encourage their migraine patients to pursue Behavioural Treatments. 1

Reasons migraine patients might start behavioural treatments include:

  • reduced frequency and severity of headache
  • reduced headache-related disability
  • reduced reliance on analgesics or pain medicines
  • more personal control over their pain 2

Listed below are some reasons why patients may prefer to use Behavioural Treatments over medicines.

  • the patient cannot tolerate medicines and/or experiences side effects
  • the patient prefers a non-drug treatment
  • the headache sufferer finds that drugs work poorly
  • female sufferers are pregnant or are planning a pregnancy
  • patients have a history of medication overuse or use of narcotics in excess
  • the patient is experiencing psychological disorders (e.g. anxiety, depression) or displays poor coping strategies. 2

Behavioural Treatments can be broken into three categories including:

  1. Biofeedback Training
  2. Stress- Management Therapy/Cognitive-Behavioural Training
  3. Relaxation Training

Biofeedback

Biofeedback training is the most successful behavioural treatment studied to date. Many children, adolescents and nursing or pregnant mothers respond very well to this treatment approach.

In the United States it is the number one biobehavioral treatment. It is used less in Canada owing to factors such as cost and insurance coverage.

Biofeedback involves the technological monitoring of physiological responses and feeding them back to the individual through a visual or auditory signal. In this way the individual learns to control physiological parameters which one is normally unable to control consciously. This ability may lead to a sense of increased control and self efficacy. In hand warming (temperature biofeedback), the goal for the patient is to volitionally warm the hands. With EMG biofeedback, the feedback is used to teach the patients to relax their muscles. 2

Biofeedback is often used in conjunction with relaxation techniques. Biofeedback Training typically requires 8-12 office visits and providers are often psychologists who also incorporate cognitive-behavioural techniques into sessions, but biofeedback may be successfully taught by a range of properly trained medical and mental health professionals. Home practice is generally encouraged between office visits. 2

The following are the most common types of biofeedback used to treat headache:

Temperature Biofeedback
Temperature biofeedback (for hand warming) is often combined with relaxation training. There are many studies in international headache journals attesting to its benefits at reducing headache pain. 3

Electromyographic (EMG) Biofeedback
Electromyographic (EMG) Biofeedback, also known as EMG, monitors electrical activity from the muscles of the scalp, neck and sometimes the upper body. Dr. Werner Becker, Neuroscience Professor (retired), Calgary, Alberta suggests it is used for muscle tension. 3

Temporal pulse amplitude Biofeedback is another biofeedback method that is used for chronic pain disorders. It has used to treat both chronic tension type headache, and migraine. The two previous types of biofeedback are the ones that psychologists and other experts use most often to assist headache patients to treat their migraines. 3

To learn more about Biofeedback visit the following website - Association for Applied Psychophysiology and Biofeedback www.aapb.org. Go to "Biofeedback Glossary". For a list of professionals that have received Biofeedback Certification visit the Biofeedback Certification International Alliance at www.bcia.org - Find a practitioner, and choose your province, then Canada.

Stress Management Therapy/Cognitive Behavioural Therapy (CBT)

Stress Management Therapy or Cognitive Behavioural Therapy (CBT) is the term used for a group of psychological treatments that are based on scientific evidence. These treatments have been proven to be effective in treating many psychological disorders.

CBT has been found to be very effective to treat migraines as a preventative, non-drug treatment approach.

Cognitive behavioural therapy (CBT) teaches the patient the role that thoughts play in generating the stress response. They are taught to employ more effective strategies in coping with stressors, including their headache attacks. The cognitive behavioural therapies used in migraine have generally included exercises to reduce dysfunctional or negative thinking and to introduce a more positive way of thinking in response to stressors and to the headache attack itself. The elimination of negative self talk and catastrophizing (a hopeless and overwhelming thinking pattern) is also a focus of CBT. Many aspects of CBT can be considered a method to improve the patient’s ability to cope with stressors and to enhance self confidence in the ability to deal with stressors (increased self efficacy). 4

In this sense, stress management can be considered to be a major focus of CBT.

Stress Management Therapy or Cognitive Behavioural Therapy (CBT) works to eliminate negative thoughts and turn them into something more productive, relieving anxiety, depression, and other things that can exacerbate head pain. - The American Migraine Foundation

Can you do CBT on yourself?

One of the goals of CBT is to "become your own therapist" by learning skills you can use on your own after treatment to keep feeling well. If you're interested in self-directed CBT, the Association for Behavioural and Cognitive Therapies maintains a list of books they've given their "seal of merit". 5

Relaxation Techniques

Relaxation Training has been around for over a hundred years, however, it is in the last decade that it has become very popular.

Relaxation Training includes techniques that focus on breathing and relaxing the mind and/or body.

Patients may use any techniques or tools that quiet the mind and calm the body, including meditation, prayer, yoga, pleasant music, guided relaxation CDs or tapes, and any other method that a patient finds effective. Relaxation training is usually taught by clinical professionals, such as psychologists or other mental health professionals, but it can also be self-taught by patients with print or audio support. 6


a) Progressive Muscle Relaxation

Progressive Muscle Relaxation is a Relaxation training procedure that focuses on helping patients modify headache-related physiological responses, reduce arousal of the nervous system, and decrease muscular tension. This common training procedure teaches patients to achieve a relaxed state through a series of muscle exercises and controlled breathing techniques. Relaxation training gives a patient increased awareness and control of biological changes that can cause headaches. 7

Below is an article on deep breathing which can be done alongside Progressive Muscle Relaxation.

Deep Breathing - To teach you deep breathing, your therapist will ask you to place one hand on your chest and one hand on your abdomen, just under your ribs, so that you are more aware of your breathing. Next, you will be asked to breathe in slowly through your nose, pulling your breath down towards your stomach, pushing your abdomen outwards, allowing yourself to fill your lungs completely. Your hand on your abdomen should rise slightly more than your hand on your chest when you are breathing deeply. Breathe out slowly, pulling your stomach in towards your spine, and think of the word “relax.” With each slow, deep breath you likely will feel yourself becoming progressively more relaxed. 8

After you have learned to breathe deeply, you will be asked to focus on slowing your breathing. For the first one to two weeks, you will probably be asked to practice this breathing exercise for five to ten minutes at a time, two to three times daily as well as during progressive muscle relaxation (PMR) training. After you have mastered the technique, you should check in with yourself throughout the day to remember to breathe deeply. Relaxation is a skill and like other skills, it can be mastered with time, practice and a good instructor. There are a variety of mind-body approaches to easing migraine pain. 8


b) Autogenic Training

Autogenic Training provides relaxation by teaching yourself how to produce a feeling of warmth and heaviness throughout your body, creating a state of physical relaxation, that can reduce your headache pain. Once you have learned this technique you can use it to: lower headache pain or overcome addictions (like smoking or gambling). 9

It was invented by a German psychiatrist Johannes Heinrich Schultz, and first published in 1932. Today it is used by psychologists as a relaxation tool that patients can learn to administer on themselves. 9


c) Mindfulness Meditation

Mindfulness meditation is a relaxation technique that allows patients to train their brain similar to the way fitness helps you to train your body. It is used to reduce headache pain, or lessen anxiety, stress or panic.

Mindfulness has been shown to be very beneficial. If you are wanting to learn Mindfulness Meditation for free, simply Google it on the internet looking for Mindfulness Meditation - from YouTube (a free tutorial).

In London a psychologist Dr. Kate Partridge administers a clinic called the London Mindfulness Clinic. See her at http://londonmindfulness.ca/ 10

*remember to include deep breathing with these Behavioural Therapies

What is Mindfulness?

Mindfulness is the psychological process of purposely bringing one's attention to experiences occurring in the present moment without judgment, which one can develop through the practice of meditation and through other training. 11

How do I find a Psychologist who treats Headache Patients?

Those who treat headaches work in a variety of settings. Some work in hospital-based headache treatment programs, while others are in hospital or clinic based behavioural medicine clinical services, or in private practice. Start by talking with your providers. Information can be gathered from Migraine Canada at www.MigraineCanada.ca. To locate Psychologists with an interest in pain go to http://www.crhspp.ca/findlist.php It is most helpful to search for psychologists who specialize in headache and/or pain management. 12

Barriers to Behavioural Treatments

In a review published in Headache (our favorite journal), Matsuzawa and colleagues have reviewed the reasons why it is so difficult to keep regular practices for behavioral habits.

Read about Barriers to adherence to behavioral approaches; What can be done by the Patient; What can be done by the Health Care Provider.

This article was recently updated by Dr. Elizabeth Leroux, Headache Neurologist, Montreal, Quebec 13

We thank her for the donation. Read the complete article here

References

  1. Wikipedia, 2019 Behavioural Medicine
  2. Non-Drug Treatments for Headache, 2013, reasons why patients may prefer to use Behavioural Treatments
  3. Biofeedback, Dr. Werner Becker, Non-Drug Treatments for Headache, book 2013
  4. Cognitive Behavioural Therapy, Dr. Werner Becker, Non-Drug Treatments for Headache, 2013
  5. CBT, Canadian Association of Mental Health, November 2016
  6. Relaxation Techniques, Brent Lucas 2018, medically reviewed by Dr. Werner Becker
  7. Behavioural and Other Non pharmacologic Treatments for Headache, American Migraine Foundation, 2019
  8. LipchikG, PhD. Ohio University Headache Centre, Westerville, Ohio - Deep Breathing
  9. Autogenic Training, The Canadian Journal of Neurological Sciences, 2016
  10. Mindfulness Mediation, The Canadian Journal of Neurological Sciences, 2016
  11. Mindfulness - Wikipedia, 2019
  12. Non-Drug Treatments for Headache, 2013, Behavioural Page 21
  13. Barriers to Behavioural Treatments (updated), Dr. Elizabeth Leroux, 2019

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