A controlled evaluation of behavioral treatment of chronic headache in the elderly

BEHAVIORTH~P~APY24, 395-408, 1993

A Controlled Evaluation of Behavioral Treatment of Chronic Headache in the Elderly NANCY L. NICHOLSON EDWARD B. BLANCHARD University at Albany, S U N Y The effects of a 12-session program combining relaxation training, cognitive therapy, and biofeedback, specifically tailored for an older population, were evaluated, using 14 elderly chronic headache (HA) patients (age range: 61-80) in 7 multiple-baselineacross-subjects design experiments. At the idiographic level, treatment was more effective than H A monitoring in 5 o f 7 experiments. At the nomothetic level, tailored treatment was also significantly (p = .05) more effective than H A monitoring in reducing HA activity as measured by daily diary. Patients consumed significantly less H A medication after treatment and were significantly less depressed and less anxious at one-month follow-up.

Almost everyone is aware of the ever-increasing numbers of elderly in American society and of the challenges to health care that this older population will represent. Among the many maladies faced by this older population is chronic benign headache (HA). While H A is relatively minor in comparison to Alzheimer's disease, cancer, or heart disease, it represents a sizable problem for older individuals. Recent epidemiological data (Stewart, Lipton, Celentano, & Reed, 1992) show that migraine H A continues to afflict approximately 10 to 15°70 of women over age 60, as well as about 5070o f men. Another survey (Cook et al., 1989) shows that 17070 of individuals over the age of 65 suffer from chronic HA. Although there is ample evidence (see Blanchard, 1992, for a recent review) that various behavioral treatments such as relaxation training, biofeedback training, and cognitive stress-coping therapy are effective with the general adult population, conventional clinical wisdom (supported by limited empirical data) was that the HAs o f older adults (usually defined as those 60 or older) were relatively unresponsive to standard behavioral techniques. For example, a retrospective review of all cases of H A patients over age 60 treated in our center

Correspondence concerning this article should be sent to Dr. Edward B. Blanchard, Center for Stress and Anxiety Disorders, 1535 Western Avenue, Albany, NY 12203. 395 0005-7894/93/0395-040851.00/0 Copyright 1993 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.

396

NICHOLSON AND BLANCHARD

revealed that only 2 of the 11 had a clinically significant reduction in HA activity (Blanchard, Andrasik, Evans, & Hillhouse, 1985). Moreover, in a meta-analytic review of the literature on behavioral treatment of tension HA, Holroyd and Penzien (1986) reported that the strongest single predictor of outcome was the average age of the sample. This variable, which loaded in a negative direction (thus indicating that older subjects responded less well), accounted for almost 30°70 of the variance in HA reduction. Over the past 4 years this "conventional clinical wisdom" has been challenged by a series of uncontrolled reports: In the first, Arena, Hightower, and Chong (1988) reported on the successful treatment of 7 of 10 elderly tension HA sufferers (age range 62 to 80) with a 7-session regimen of progressive muscle relaxation (PMR). The key feature of this successful treatment program, according to Arena et al. (1988), was spending enough time with patients to ensure that they fully understood the procedures. Some modifications were also made to the PMR regimen (adapted from that of Blanchard & Andrasik, 1985) for the older population, such as taking care not to use full isometric contractions of some muscle groups in instances in which this might cause discomfort. This specific tailoring of the treatment protocol to the needs of the older population has been a feature of all recent reports on the treatment of older HA patients. A later uncontrolled study by Arena, Hannah, Bruno, and Meador (1991) reported significant improvement among 8 elderly tension HA patients treated with 12 sessions of frontal EMG biofeedback, again tailored to the older population; 50070were clinically improved. An uncontrolled prospective study from our center (Kabela, Blanchard, Appelbaum, & Nicholson, 1989), following Arena's advice about tailoring the treatment to the information-processing abilities of the older population, found 63070 of the population (8 tension, 6 mixed, and 3 migraine HA sufferers, who ranged in age from 60 to 77) to be clinically improved. Given this record of success in prospective, but uncontrolled, studies of various behavioral treatments of HA, the next logical step seemed to be a controlled evaluation. Thus the present paper reports on 7 multiple-baseline-acrosssubject experiments (Hersen & Barlow, 1976), comparing a multicomponent behavioral treatment tailored to the information-processing abilities of older patients to continued HA monitoring in a population ranging in age from 61 to 80. As such it represents, to the best of our knowledge, the first controlled evaluation of behavioral treatments for chronic benign HA in the elderly.

Methods

Subjects Nineteen patients were initially assessed and started in baseline HA recording; 3 dropped out in baseline due to other time commitments. One patient dropped out of treatment due to hospitalization for a myocardial infarction and another apparently lost interest during treatment, leaving 14 who completed treatment and short-term follow-up. Patients were formed into dyads based on diagnosis and baseline HA activity, with secondary matching on sex and age

m3AOACm~

397

TABLE 1 SUBJ]~CT D ~ M O G ~ m c DATA

Sex

Age

Marital status

Employment

Education (years)

Years of HA

1 Tension 2 Tension

M F

61 65

Divorced Divorced

Full-time Retired

18 14

11 45

3 Tension 4 Tension

F F

64 80

Single Divorced

Part-time Retired

18 8

25 59

5 Mixed 6 Mixed

M F

61 68

Married Married

Full-time Retired

18 12

30 15

7 Mixed 8 Mixed

F F

66 69

Married Married

Retired Retired

17 12

34 65

9 Mixed 10 Mixed

F F

63 61

Married Married

Retired Part-time

13 14

38 51

11 Migraine 12 Migraine

M M

73 75

Married Married

Part-time Part-time

16 19

36 40

13 Migraine 14 Migraine

F F

63 64

Married Married

Retired Never

12 12

30 48

Diagnosis

Treatment pairs

as possible, and were randomly assigned to either a 4-week or 12-week period of baseline H A monitoring. The treatment dropouts were replaced in the dyads with patients who matched on diagnosis. Demographic characteristics of the sample who completed treatment are contained in Table 1. Diagnosis was made on the basis o f Ad Hoc Committee (1962) criteria by an advanced doctoral student in clinical psychology who had 3 years o f experience in the assessment and treatment of chronic HA. (This individual [NLN] also conducted all treatments.) A second diagnosis was obtained from each patient's neurologist. There was perfect agreement on diagnosis after conferencing. The completed study consists of 7 pairs of subjects, 10 females and 4 males between the ages o f 61 and 80 (X = 66.7 years). Four subjects were diagnosed with tension HA, 4 with migraine HA, and 6 with both H A types (mixed). Duration of HAs ranged from 11 to 65 years (X = 37.6 years). Assessment At the initial visit patients were given instruction in completing a daily H A diary that provided the primary dependent variable for this study. Subjects rated their H A severity four times daily on a 6-point scale (0 = no H A to 5 = intense, incapacitating HA). This diary had been used successfully with older populations in the two previous studies in this center and has adequate

398

NICHOLSON AND BLANCHARD

reliability and validity (Blanchard & Andrasik, 1985). The subjects also recorded daily medication usage, which was evaluated using a potency scale developed by Coyne, Sargent, Segerson, and Obourn (1976). (Although this is a standard procedure in the H A area, it should be noted that we have no independent corroboration of medication intake.). Psychological assessment. Subjects were tested for memory function using the Wechsler Memory Scale-Revised (WMS-R) (Wechsler, 1987). The W M S - R appears to be a valid measure of global cognitive status and attention/concentration, which were the factors of primary interest for this study. No noticeable impairment of memory was found with general memory subscale scores ranging from 98 to 130. Scores on the Mini Mental Status Examination for all subjects were 30 (indicating no gross impairment). Past or present occurrence of major psychological symptoms and treatment was assessed by brief structured interview (see Blanchard & Andrasik, 1985). Current levels of anxiety and depression were assessed using the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Lushene, 1970) and the Geriatric Depression Scale (Brink et al., 1982), respectively.

Treatment Treatment consisted o f 12 sessions, 90 minutes in length, over an 8-week period. Weeks 1, 2, 5, and 6 required 2 sessions each week, with the remaining 4 weeks having one session each. The first 4 weeks (6 sessions) were devoted to progressive muscle relaxation (PMR) training and the introduction to the cognitive-therapy component of treatment. The second 4 weeks (6 sessions) consisted of biofeedback training and the remainder of the cognitive-therapy component. P M R training was administered as previously detailed by Blanchard and Andrasik (1985). Both subjective ratings of relaxation (scale 1 = normal state to 10 = extremely relaxed) and therapist ratings of relaxation (BRRS Scale, Poppen, 1988, ranging 0 = low to 10 = high relaxation) were recorded in each session. Subjects recorded relaxation ratings for home practice sessions in the H A diary. Biofeedback consisted of 6 sessions (16 minutes in length) using the Commodore Biopro biofeedback software. Those subjects with tension H A (n = 4) received EMG biofeedback from either the frontalis (n = 1) or the trapezius (n = 3), depending on the subject's perception o f which area was most related to his or her HA, a practice recommended by Hudzinski (1983). E M G measures were recorded during each session from silver-silver chloride electrodes with standard application and skin preparation. Subjects with migraine H A or combined tension and vascular H A types (n = 10) received 6 sessions of thermal biofeedback. They were also loaned a digital thermometer and instructed to practice twice daily at home. The cognitive therapy component consisted o f instruction and practice of either stress-coping techniques or problem solving, based upon therapist's assessment of the individual patient and following the practice described by Tobin, Holroyd, Baker, Reynolds, and Holm (1988). Stress-coping training consisted o f the program described by Holroyd, Andrasik, and Westbrook (1977). Nine

m~AD^cm~

399

patients received this treatment. The problem-solving component was based on the approach originated by D'Zurilla and Goldfried (1971) and was tailored after the 5-step plan outlined in McKay, Davis, and Fanning (1981). Subjects worked through the 5 steps of the plan within the treatment sessions over 2 to 3 weeks, using the identified problem of their choice. A second problem was worked through using a combination of in-session guidance and homework. Five patients received this treatment. There were no differential effects of the two cognitive-therapy treatments. Modifications of treatment for an elderly population. The following modifications were made for this elderly population: (1) Session length was increased by 50% to a total of 90 minutes. The extra time was utilized to insure comprehension of the materials by using such methods as review of materials from homework or the prior session. (2) Home practice for the PMR training was guided by audiotapes until we reached the 4-muscle-group exercise. This eliminated the need for the memorization by the patient of the longer exercises. (3) The therapist was in the room during all biofeedback sessions to provide guidance and verbal feedback when necessary. Verbal feedback from the therapist at the end of the session was directed toward praising performance and gentle encouragement. Attempts were made to reassure subjects that their performance was not unexpected when the subjects had initial difficulty or had a later session at which performance deteriorated. (4) All instructions, explanations, homework assignments, and program outlines were provided to the subjects in written form to supplement the verbal presentations.

Follow-up Subjects were required to continue to maintain HA dairy recording for 4 weeks after the last treatment session. At the end of that 4-week posttreatment phase, subjects returned to the clinic for a follow-up assessment. At that time a review of all techniques was conducted, including a biofeedback treatment session. The GDS and STAI were also administered posttreatment. Treatment credibility was assessed at pretreatment and posttreatment with a locally designed instrument that has been used previously (Blanchard et al., 1990). At follow-up, patients rated the degree of change in their HA activity on a visual analogue scale ranging from -100 (extremely worse) to 0 (no change) to + 100 (completely improved).

Results Headache Measures Following convention, the HA data were converted to an average weekly HA index by summing all 28 ratings from the week and dividing by 7. This yields an average daily HA activity score (range 0 to 20) or HA index. The weekly HA data for subjects who completed the study are shown in Figure 1. Examination of these data indicates that in 5 of 7 pairs (pairs #1, 2, 3, 6, and 7) the HA index decreased for the treated subject while the HA activity for the symptom-monitoring member of the pair remained unchanged. Thus, in 5 of the 7 multiple-baseline-across-subject experiments, the data clearly sup-

400

NICHOLSON

Pre Baseline

AND

BLANCHARD

Post Baseline

Treatment

Pair 1 Tension HA S#1

i

: ....

Tension HA S#2 2 x "c0

1

e-(3

0

Pair 2 Tension HA S#3

"1-

..................................

i

8

Tension HA S , 4

4

3

5

7

9

11

~13

15

17

19

21

23

25

Weeks FIG. 1. Weekly values of Headache Index for each pair of patients across all phases of the experiment. Data from both members of a pair are plotted on the scale; however, the scale varies from pair to pair. (Fig. 1 continues on pages 401 and 402.)

401

HEADACHE

Pre

Baseline 6

Treatment

Post Baseline

Pair 3

Mixed HA S#5

:

:~

~

............... IH ~ .

MixedHA S#6

x

Pair 4

"(3 =

Mixed HA S#7

¢{J 6~k

...................................i

Mixed HA S#8

"1-

12L lO 8 6 4 2 o 6

Pair 5

Mixed HA S#9

...................................:

1

3

5

7

9

1

:13

Mixed HA S#10

1-5

Weeks

17

19"- 2-1

23

25

402

NICHOLSON A N D BLANCHARD

Pre Baseline

Post Baseline

Treatment

Pair 6 Migraine HA S#11

5

! Migraine HA S#12

4 3 2

V

1 x "O

Pair 7 Migraine HA S#13

cO "0 "r

14 12 10 Migraine HA S#14

8 6 4 2 0

3

5

7

9

11

13

15

Weeks

17

19

21

23

H~ADACHE

403

ported the efficacy o f t r e a t m e n t over s y m p t o m m o n i t o r i n g . I n 3 o f the 7 H A m o n i t o r i n g subjects (subjects #2, 4, a n d 10), decreases in H A activity were n o t e d d u r i n g the s u b s e q u e n t active t r e a t m e n t phase, i C o n s u m p t i o n o f m e d i c a t i o n s for H A relief is a potentially c o n f o u n d i n g factor in e v a l u a t i o n o f t r e a t m e n t outcome. E x a m i n a t i o n o f the weekly medic a t i o n c o n s u m p t i o n data reported by i n d i v i d u a l subjects d u r i n g baseline a n d t r e a t m e n t c o n d i t i o n s indicated m e d i c a t i o n usage either r e m a i n e d stable or decreased c o n c u r r e n t with H A r e d u c t i o n for all b u t o n e subject (#12). I n n o case did H A r e d u c t i o n c o r r e s p o n d with a n increase i n m e d i c a t i o n c o n s u m p t i o n . 2

Clinically Significant Improvement Treatment efficacy c a n also be analyzed in terms o f clinically significant imp r o v e m e n t ( B l a n c h a r d & Schwarz, 1988). Following established c o n v e n t i o n , we defined clinically significant i m p r o v e m e n t as 50% or greater r e d u c t i o n in H A activity as m e a s u r e d by H A index using the following formula: Percent = 100 x reduction

(pre-tx H A index - post-tx H A index) pre-tx H A index

Table 2 lists the i n d i v i d u a l percent r e d u c t i o n scores for each subject as a result o f t r e a t m e n t (or as a result o f s y m p t o m m o n i t o r i n g as well as treatment) for both H A a n d medication indices. The overall sample treatment effects i n terms o f percent reduction in H A activity from p r e t r e a t m e n t to posttreatm e n t are included in Table 2 a n d indicate that 50°70 of the overall sample reached clinically significant levels o f improvement.

Psychological State Measures I n d i v i d u a l patient scores o n the pre- a n d p o s t t r e a t m e n t measures o f depression a n d anxiety are presented in Table 3. Significant reductions were f o u n d

1 It is possible to construe the study as a 2-group design; consequently, all subject data were collapsed to form two groups, with the treated members of the pairs forming a treatment group and the HA-monitoring members forming a symptom-monitoring control group. An average HA index was calculated for each treated subject using the data from the 4 weeks of pretreatment baseline and from the 4 weeks of follow-up. The control-group indices were calculated using the first 4 weeks of symptom monitoring as a baselineand the last 4 weeks of symptom monitoring as a measure corresponding to the follow-up period. There were no significantdifferencesbetweenthe groups on pretreatment HA measures. Headache indiceswere subjectedto a two-way(Group × Time) repeated measuresANOVAthat yielded a significant main effect of Time, F(1,12) = 17.16,p = 0.001, and an interaction of Group × Time, F(1,12) = 4.77, p = 0.05. Post hoc analyses of this interaction were conducted by t tests on each group to assess within-group change. A significant reduction in HA index was found for the treated group, t(6) = 4.56,p = .004, with a nonsignificant reduction noted in the control group, t(6) = 1.36, p = .22. 2 Medication consumption is summarized in a weekly Medication Index by multiplying the number of doses of any HA medication (number of pills) by its potency from the Coyne et al. 0976) scale and then summing the total values for one week.

404

NICHOLSON AND BLANCHARD TABLE 2 PERCENT REDUCTIONIN HEADACHEAND MEDICATIONINDICESBY SUBJECTFOR BOTH SYMPTOMMONITORINGAND TREATMENTCONDITIONS Headache Symptom monitoring

Subject No.

Medication Active treatment

Symptom monitoring

Active treatment

1 2

16%

84070 50%

22%

40% - 5%

3 4

- 10070

33070 91 070

- 142%

260/o 72%

5

500

67%

6

4070

19070

7070

13070

7 8

64o70

31070 - 23070

57070

0070 6°/0

9 10

65070

7O7o 89070

100070

3°70 0070

11 12

17070

800/o - 7O/o

100070

100°7o - 40070

13 14

- 6°7o

60°70 - 2707o

38%

46o/o 23 °70

Frequencies of percent reduction in headache activity Unchanged or worse <250 5 (35°70)

Slightly improved 25% to 49°70 2 (14070)

Clinically improved 50070 to 74% 75°7o+ 3 (22070) 4 (29°70)

in b o t h d e p r e s s i o n , t(13) = 2.49, p = .03, a n d state anxiety, t(13) = 2.37, p = .03, w i t h n o c h a n g e seen in trait a n x i e t y scores. A l t h o u g h m o s t s u b j e c t s s h o w e d little d e p r e s s i o n , t h e 4 w h o were n o t i c e a b l y d e p r e s s e d all s h o w e d m e a n i n g f u l r e d u c t i o n s .

Process Measures T r e a t m e n t c r e d i b i l i t y was m e a s u r e d pre- a n d p o s t t r e a t m e n t o n a 10-point scale (1 = n o t at all l o g i c a l , 10 = v e r y logical). P r e t r e a t m e n t r a t i n g s r a n g e d f r o m 8 to 10 ( X = 9.71). P o s t t r e a t m e n t ratings r a n g e d f r o m 5 t o 10 ( X = 9.21), i n d i c a t i n g a n o n s i g n i f i c a n t d e c r e a s e in c r e d i b i l i t y f r o m pre- to p o s t treatment. M e a s u r e s o f r e l a x a t i o n in session s h o w e d all s u b j e c t s r e a c h e d n e a r m a x i m a l levels o f r e l a x a t i o n as m e a s u r e d by s u b j e c t i v e ratings o f r e l a x a t i o n (8.4 o u t o f 10) a n d t h e r a p i s t r a t i n g o n t h e B R R S ( P o p p e n , 1988) (9.1 o u t o f 10, w i t h 12 o f 14 at 9 o r h i g h e r ) by S e s s i o n 6. I n s p e c t i o n o f the in-session t e m p e r a t u r e d a t a for highest t e m p e r a t u r e reached

405

HEADACHE TABLE 3 PSYCHOLOGICAL TEST SCORES BY SUBJECT

Subject

Anxiety

Geriatric Depression Scale

State

Trait

No.

Pre

Post

Pre

Post

Pre

Post

1 2 3 4 5 6 7 8 9 10 11 12 13 14

4 3 3 6 16 11 14 7 9 5 4 4 14 1

3 2 6 4 6 5 6 8 5 6 2 3 5 2

33 35 37 39 38 34 41 26 44 31 32 31 43 27

45 29 29 28 34 36 39 21 36 25 31 24 26 28

34 37 31 39 44 33 55 35 39 42 35 31 42 26

32 35 36 38 42 31 45 47 31 39 37 27 35 33

per session and for the temperature change in the session indicated that all subjects achieved some degree of success in handwarming with 8 of 10 reaching 95 ° F at some point in treatment. In-session E M G biofeedback measures showed that all subjects in this condition were able to decrease muscle tension, as noted by the decreases in lowest E M G recorded and the decrease in session of mean EMG. Daily h o m e practice o f techniques was encouraged of all subjects. Subjects reported practice sessions on the H A diary; these data indicate that most subjects complied with some degree of h o m e practice, but there was marked variability in compliance with the daily recommended practice. All subjects averaged 4 or more practices per week. There was no significant relationship noted between the percent of reduction in H A activity and the degree of success in either subjective or observed relaxation ratings, r(12) = .21, or between the percent of reduction in H A activity and the degree of measured physiological change during biofeedback, EMG, r(12) = .40; thermal, r(8) = -.36; or compliance with h o m e practice, r(12) = .05. A strong positive correlation, r(12) = .92, p = .0001, was found between subjective estimates of reduction in H A activity and calculated reduction scores (Table 2). A significant negative correlation was found between years o f H A activity and percent reduction in HA, r(12) = -.59, p = .01. This would suggest that it is an important matching variable for future research in this area. No significant relationship was noted between other pretreatment psychological measures or demographic data and outcome.

406

NICHOLSON AND BLANCHARD

Discussion To the best of our knowledge this represents the first controlled trial o f nondrug treatment for an elderly H A population. The results of this study show a clear advantage of active non-drug treatment of H A in this older population when compared experimentally to H A monitoring alone. The percentage o f the overall sample that achieved clinically significant reductions in H A activity (50%) is within the 40 to 80% improvement range in general adult populations treated with similar methods, as reported by Blanchard (1992). These present results are also consistent with the prior studies in the geriatric population that report 50 to 70% of samples reaching clinically significant levels o f improvement (Arena et al., 1988; Arena et al., 1991; Kabela et al., 1989). All o f these previous studies were uncontrolled. Because the use o f medications for H A control represents a possible confounding influence on change in HA, we examined the relationship between H A activity and medication consumption. The decreases in H A activity seen in this sample were not related to a concomitant increase in medication consumption. Instead, there was a significant overall decrease in H A medication consumption from before to after treatment. This finding leads us to conclude that these positive outcomes can be interpreted unambiguously. The treatment procedures o f the present study were designed, or tailored, for a geriatric population based on our prior experience with older H A sufferers (Kabela et al., 1989) and on the suggestions made by Arena et al. (1988). These adaptations included allowance of adequate time for explanations, questions, and answers; repetition of information in simple terms; and provision of written materials. Although these adaptations proved useful for several subjects in this study, for some they were unnecessary and, anecdotally, were interpreted by the subjects as insulting. There was also variability in the individual subjects' use of written materials and reminders. Several subjects utilized the written materials extensively, reporting that they posted materials in obvious places in their homes as reminders. Other subjects reported that they did not need to refer to the materials and had either misplaced them or put them away for future reference Still others utilized written reminders of appointment schedules and major points but did not report the use of written materials on techniques. Thus, with this process variable, as with the others described earlier (e.g., home practice frequency, degree of relaxation), we find no systematic relation to our outcome variable o f headache reduction. On the basis o f the experience of treating this present study sample, one comes to the conclusion that flexibility is the key to working with this older population. An approach that recognizes the necessity o f evaluating the individual subject and o f utilizing an approach that matches the individual's cognitive capacity would seem to be essential. This would seem to be an approach that combines common sense, careful assessment, and good clinical judgment--factors that are not related to subject age. The findings of decreases in depression and state anxiety scores are consistent with those reported elsewhere (Blanchard et al., 1986) but are the first

I-~EADACI-m

407

such data available on an elderly H A population. At posttreatment all but one subject reported feeling that they derived benefit from the treatment in terms o f feeling more relaxed and more positive about their ability to deal with stress. This positive evaluation of the experience was not solicited by the experimenter, nor was it related to degree of H A reduction. From this study, we cannot determine whether the tailoring of the treatment was necessary or not. What would be necessary to answer that question would be a study in which a portion of elderly patients were randomly assigned to the "tailored" regimen while a comparable group were assigned to the "standard" regimen. Data from our two previous uncontrolled studies ("standard" regimen in Blanchard et al., 1985; "tailored" regimen in Kabela et al., 1989) suggest the importance; only the true experimental comparison will provide a clear answer. Several factors limit the generalizability of the present study to the elderly population at large. First, this sample was drawn from a high-functioning, relatively healthy, community-dwelling population. They could be best described as the "young-old" segment o f the older adult population. Patients with more physically debilitating disorders or patients o f declining cognitive function may present difficulties in the effective application of these types o f treatment. Second, the treatment package was developed to maximize treatment efficacy for this population and therefore consisted of a multicomponent approach utilizing a number of treatment methods. Given this, for those subjects who showed clinically significant improvement, it is not possible to determine the efficacy o f the individual treatment components or the necessity o f a multifaceted treatment approach. Despite these limitations, to the best o f our knowledge this is the first controlled treatment study undertaken with this geriatric population of H A sufferers. The findings presented here are consistent with the small, but growing, body o f literature that suggests that this older population can benefit from the same non-drug treatments as their younger counterparts.

References Ad Hoc Committee on the Classification of Headache (1962). Classification of headache. Journal of the American Medical Association, 179, 717-718. Arena, J. G., Hannah, S. L., Bruno, G. M., & Meador, K. J. (1991). Electromyographic biofeedback training for tension headache in the elderly: A prospective study. Biofeedback and Self-Regulation, 16, 379-390. Arena, J. G., Hightower, N. E., & Chong, G. C. (1988). Relaxation therapy for tension headache in the elderly: A prospective study. Psychology and Aging, 3, 96-98. Blanchard, E. B. (1992). Psychological treatment of benign headache disorders. Journal of Consuiting and Clinical Psychology, 60, 537-551. Blanchard, E. B., & Andrasik, E (1985). Management of chronic headache: A psychological approach. Elmsford, NY: Pergamon. Blanchard, E. B., Andrasik, E, Appelbaum, K. A., Evans, D. D., Myers, P., Barron, K. D. (1986). Three studies of the psychological changes in chronic headache patients associated with biofeedback and relaxation therapies. Psychosomatic Medicine, 48, 73-83.

408

NICHOLSON AND BLANCHARD

Blanchard, E. B., Andrasik, E, Evans, D. D., & Hillhouse, J. 0985). Biofeedback and relaxation treatments for headache in the elderly: A caution and a challenge. Biofeedback and SelfRegulation, 10, 69-73. Blanchard, E. B., Appelbaum, K. A., Radnitz, C. L., Morrill, B., Michultka, D., Kirsch, D., Guarnieri, P., Hillhouse, J., Evans, D. D., Jaccard, J., & Barron, K. D. (1990). A controlled evaluation of thermal biofeedback and thermal biofeedback combined with cognitive therapy in the treatment of vascular headache. Journal of Consulting and Clinical Psychology, 58, 216-224. Blanchard, E. B., & Schwarz, S. P. (1988). Clinically significant changes in behavioral medicine. Behavioral Assessment, 10, 171-188. Brink, T. L., Yesavage, J. A., Lum, O., Heersema, P. H., Adey, M., & Rose, T. S. (1982). Clinical Gerontologist, 1, 37-43. Cook, N. R., Evans, D. A., Funkenstein, H., Scherr, P. A., Ostfeld, A. M., Taylor, J. O., & Hennekens, C. H. (1989). Correlates of headache in a population-based cohort of elderly. Archives of Neurology, 46, 1338-1344. Coyne, L., Sargent, J., Segerson, J., & Obourn, R. (1976). Relative potency scale for analgesic drugs: Use of psychophysical procedures with clinical judgments. Headache, 16, 70-71. D'Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal o f Abnormal Psychology, 78, 107-126. Hersen, M., & Barlow, D. H. (1976). Single case experimental designs." Strategies for studying behavior change. NY: Pergamon. Holroyd, K. A., Andrasik, E, & Westbrook, T. (1977). Cognitive control of tension headache. Cognitive Therapy and Research, 1, 121-133. Holroyd, K. A., & Penzien, D. B. (1986). Client variables in the behavioral treatment of current tension headache: A meta-analytic review. Journal of Behavioral Medicine, 9, 515-536. Hudzinski, L. G. (1983). Neck musculature and EMG biofeedback in treatment of muscle contraction headache. Headache, 23, 86-90. Kabela, E., Blanchard, E. B., Appelbaum, K. A., & Nicholson, N. (1989). Self-regulatory treatment of headache in the elderly: An answer to the challenge. Biofeedback and Self-Regulation, 14, 219-228. McKay, M., Davis, M., & Fanning, P. (1981). Thoughts and feelings." The art of cognitive stress intervention. Oakland, CA: New Harbinger Publications. Poppen, R. (1988). Behavioral relaxation training and assessment. Elmsford, NY: Pergamon. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). STAI Manual for the State-~ait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Stewart, W. E, Lipton, R. B., Celentano, D. D., & Reed, M. L. (1992). Prevalence of migraine headache in the United States. Journal of American Medical Association, 167, 64-69. Tobin, D. L., Holroyd, K. A., Baker, A., Reynolds, R. V. C., & Holm, J. E. (1988). Development and clinical trial of a minimal contact, cognitive-behavioral treatment for tension headache. Cognitive Therapy and Research, 12, 325-339. Wechsler, D. (1987). WechslerMemory Scale-Revised. NY: The Psychological CorporationHarcourt Brace Jovanovich. RECEIVED: November 17, 1992 ACCEPTED: February 19, 1993