Psychological treatments for migraine

Biomed

& Phannacother

1996;50:58-63

0 Elsevier,

Dossier

“Migraine

Paris

II”

Psychological

treatments for migraine

GJ Reid, PJ McGrath Psychology

Department,

IWK-Grace

Health

Centrr,

5850

University

Avr,

Hd~fu.x,

Summary - Psychological and behavioral treatments for migraine are described Treatments for children, adolescents, and the elderly, and for menstrual migraine and stress-coping treatments have all demonstrated effectiveness. These treatments sufferers and treatment effects are reliably maintained for periods of at least one behind the efficacy of psychological treatments. Suggestions for future research treatment effectiveness, and increasing the acceptance of psychological treatments migraine

/ psychological

Nova

Scotia,

B3J 3GY,

Cnnnda

and evidence for their efficacy is reviewed. are then discussed. Biofeedback, relaxation, are effective for the majority of migraine year. Little is known about the mechanism on treatment mechanisms, enhancement of are provided.

treatment

INTRODUCTION Migraine headache is a common disorder among both adults [41] and children and adolescents [30, 501. The present article will focus on treatments specifically for migraine, although many individuals with migraine also suffer from tension headache [41]. Migraine is associated with significant disability for adults [14], and children with migraine experience levels of disability similar to children with other types of chronic illnesses [36]. The physiological mechanisms of migraine are being unravelled [37]. However, specific triggers for the onset of migraine are less well-defined. A large number of factors have been suggested as potential triggers for migraine (eg. bright light, specific foods, alcohol) [40], but few specific triggers have been reliably demonstrated to be associated with migraine onset. Stress appears to be an exception; a number of studies have found stress to be a trigger for migraine 127, 431. Although stress may be a trigger for migraine events, there is little evidence that migraineurs suffer more stress or have more emotional problems than non-migraineurs [ 111. Despite the lack of empirical support for specific psychological factors as causes of migraine, the efficacy of psychological and behavioral treatments is well established. Relaxation [4] and fingertip thermal biofeedback [ 161 are the two most commonly used

and extensively validated behavioral treatments. Cognitive-behavioral therapy or stress-coping training has received considerable support 145, 541. Electromyographic (EMG) [20] and cephalic artery blood volume pulse (BVP) biofeedback [17] have also been investigated. Operant behavioral techniques are widely used in the treatment of chronic pain but have not been extensively examined with respect to migraine [42]. Exercise has also been suggested as a treatment [12, 511 but the efficacy is uncertain [32]. We will review the validated treatments for migraine in adults. Treatments that have no or limited efficacy data will not be reviewed. Consideration will then be given to migraine treatments for children and the elderly, and for menstrual migraine. Finally, mechanisms of psychological/behavioral treatments will be discussed. PSYCHOLOGICAL AND BEHAVIORAL TREATMENTS The initial phases of treatment for migraine tend to be similar regardless of the treatment modality used. Most treatment programs have participants record their headaches using a headache diary. Typically, participants record the intensity and duration of their headaches and medication usage four times per day. Changes in headache frequency, intensity, and duration, based on diary recordings, have become the standard for judging

Psychological

treatments

treatment efficacy in migraine research. Depending on the treatment, possible triggers, stressors, mood, and self-statements may also be recorded. Most treatment programs provide education about migraine and its causes, and a rationale for the specific treatment. Idiosyncratic migraine triggers and the importance of minimizing exposure them are also discussed. Relaxation Relaxation is probably the most widely used psychological method for treating migraine. A variety of techniques may be used, including muscle relaxation, autogenic phrases [47], guided imagery [24], and diaphragmatic breathing [I]. Muscle relaxation, based on Jacobson’s [25] progressive muscle relaxation, involves alternating contraction and relaxation of specific muscle groups, and teaches muscle control and awareness of tension in addition to relaxation. Relaxation training using autogenic phrases [49], involves having participants learn a series of statements related to calmness, warmth, and heaviness designed to enhance relaxation (eg, “Your body feels heavy and relaxed” or “Your hands are getting warmer”). Guided imagery treatments engage participants in a series of exercises in which they visualize themselves in settings related to feelings of safety, warmth, and tranquillity (eg, sitting in front of a fireplace); these settings may be recollections of the participant or may be created by the therapist. Finally, diaphragmatic or abdominal breathing teaches participants to take slow, deep breaths by inhaling through the nose, gently expanding the abdomen, and exhaling through the mouth; this method of breathing decreases hyperventilation and facilitates relaxation. Typically, these methods of relaxation training are combined [44].

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back, participants are encouraged to alter their physiological responses using whatever means they can or, in the case of thermal biofeedback, they may be provided with autogenic phrases related to warmth. Since Sargent and colleagues [48] discovered that finger warming could have positive effects on migraine, multiple clinical trials have demonstrated the efficacy of thermal biofeedback as a treatment for migraine [7, 3 1, 471. EMG biofeedback of the frontalis or trapezius muscle and cephalic artery BVP biofeedback have also been used for migraine but less extensively than thermal biofeedback [ 18, 201. Stress-coping

training

Stress-coping treatments target participants’ understanding of the relation between cognitions and stress and ways to modify their exposure to, appraisal of, and coping with stressful situations [7, 45, 531. Typically. participants first learn to monitor their thoughts and feelings in response to stressful situations. Means of controlling negative thoughts (eg, reformulating thoughts, attention diversion) and increasing positive self-statements are then taught. Unrealistic or maladaptive beliefs and attitudes are examined and ways to alter these beliefs are discussed. Participants may also explore ways to anticipate and prepare for stressful encounters, Problem solving and assertive training may be additional components of the treatment. In clinical practice relaxation, biofeedback, and stress-coping are usually combined to provide a comprehensive treatment package. Individuals prefer different strategies and may find that some strategies are uncomfortable or inappropriate for them. Providing a comprehensive treatment package allows participants to select the strategies that they find most helpful. TREATMENT

EFFICACY

Biofeedback Biofeedback involves amplification and display, either visual or auditory, of specific physiological events. When provided with this information, individuals can learn to modify physical processes that are not normally under voluntary control. Biofeedback sessions typically have participants sit quietly for approximately five minutes to acclimatize to the treatment room and then provide 30 to 35 minutes of feedback. During the feed-

Whether administered singly or in combination, these treatment techniques demonstrate improvements on outcomes such as the frequency, intensity, and duration of headaches, and medication use. Percent improvements of headache activity range from 30-60% depending on the study and outcome variable [2, 4, 6, 8, 9, 16, 24, 47, 531. Using 50% reduction in headache activity as a clinically significant improvement, 30-60% of participants usually benefit from treatment com-

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GJ Reid,

pared to lo-20% of controls [6, 8, 451. Long-term follow-up studies have found treatment gains are maintained for periods of one to four years [3, 4, 24, 31, 531. Studies comparing various psychological/behavioral treatments tend to find that no one treatment is more efficacious than another [19, 44, 47, 541. There is a lack of studies comparing active treatments to placebo. An exception is Blanchard et al [7] who compared a) pseudomeditation, b) thermal biofeedback and relaxation with cognitive-behavioral treatment, c) thermal biofeedback and relaxation without cognitive-behavioral treatment, and d) wait-list controls; no significant differences between the biofeedback and pseudomeditation groups were found but all three were improved compared to the wait-list controls. There are also few studies that have compared psychological and pharmacological treatments. Recent studies by Holroyd et al [22, 231 found that the combination of thermal biofeedback and relaxation (53% of participants clinically improved) was as effective as an abortive drug treatment (ergotamine tartrate; 61% of participants clinically improved). There have been no studies comparing psychological treatments to the new generation of migraine drugs such as sumatriptan. SPECIAL

ISSUES IN MIGRAINE TREATMENT

Children/adolescents Psychological treatments for migraine in children and adolescents are similar to those for adults. Labbe and Williamson [29] first demonstrated that children trained to use thermal biofeedback and autogenic statements had significantly reduced migraine headaches compared to wait-list controls. Subsequently, thermal biofeedback has been the most extensively investigated treatment for migraine in children and adolescents [lo, 15, 21, 281. Other studies have examined relaxation [33, 461 and stress-coping training [34, 391. Percent improvements range from 35-100% with maintenance of treatment gains lasting at least one year. Improvements in the frequency of headache have been found more consistently than decreases in intensity [ 131; however, many studies utilize the headache index which combines intensity, frequency, and duration ratings making it impossible to see if specific treatments have

PJ McGrath

differential effects on these aspects of migraine. Clinically significant improvements (50% reduction in headache) have been found for 60-100% of participants compared to about 20% (range O60%) of controls [2, 10, 28, 34, 39, 551. Only one study has compared psychological and pharmacological migraine treatments among children and adolescents. Olness et al [38], using a withinsubjects design, suggested that relaxation and imagery (termed self-hypnosis by the authors) was more effective than propranolol in decreasing the frequency of migraines among children. The elderly Migraine prevalence decreases markedly after approximately age 45 years with estimates of 12% among 45-54 year olds compared to 34% among 25-34 year olds [41]. Few studies have tested the efficacy of psychological treatments for migraine in older adults. Kabela et al [26] found significant decreases in headache among adults 60-77 years old following treatment using a combination of relaxation, biofeedback, and stress-coping training. Blanchard [2] suggested longer sessions and ensuring comprehension of instructions when providing treatment for older adults. Menstrual

migraine

More women suffer from migraine than men [41]. A subset of women experience menstrual migraine, defined as migraines that occur during, or within three days before or after the menstrual period [52]. Gauthier et al [ 191, using within-subjects analyses, found that cephalic artery BVP biofeedback or thermal biofeedback were equally effective for both menstrual and nonmenstrual migraines. Comparisons between subjects classified as having predominantly menstrual migraine (66% or more of migraines occurred during the menstrual period), non-mensural migraine (66% or more of migraines occurred outside the menstrual period) or undetermined, revealed treatment was equally effective for all three groups; however, no control group was used in the study. Solbath et al [52] identified a subset of women from a larger study [47] who had menstrual migraine; unlike Gauthier et al [19], the authors did not specify the percent of total migraines that occurred during the menstrual period. Solbach et al [52] found significant improvements for all

Psychological

treatments

groups, but no group differences, among women who received autogenic training, EMG biofeedback, thermal biofeedback, or no treatment. Lack of a control group in the Gauthier et al [ 191 study and lack of within-subjects analyses comparing treatment effects for menstrual versus non-menstrual migraines in the Solbach et al [52] study make it difficult to make a general conclusion from these studies. Psychological treatments for menstrual migraine appear promising but controlled outcome studies addressing the limitations of previous research are needed.

Minimal-therapist

contact treatments

In an attempt to make psychological treatments more cost-effective, several researchers have investigated the efficacy of delivering treatments by means of manuals and tapes with minimal-therapist contact. In both adolescents [ 10, 2 1, 341 and in adults [5, 6, 451, minimal-therapist contact treatments have proven to be as effective as therapist mediated treatment and are much more costeffective.

MECHANISMS

IN PSYCHOLOGICAL TREATMENTS

The mechanisms of action of psychological treatments have not been widely investigated. A vascular model of migraine would suggest that the efficacy of thermal or BVP biofeedback is due to direct changes in the reactivity of the vascular system. Thermal biofeedback has been shown to alter the ability of individuals to increase their finger temperature [7, 8, 21, 39, 531. Based on results of a number of studies, Blanchard [2] suggested that individuals must reach a “therapeutic threshold” of 95-96 “F in raising their hand temperature in order for changes in migraine activity to be evidenced. However, a dose-response relationship between the ability to increase fingertip temperature and changes in migraine activity has not been demonstrated [21, 35, 39, 531. Some studies suggest that any type of biofeedback (EMG, thermal, BVP) or relaxation produces a generalized decrease in autonomic arousal [ 18, 35, 471. In general, the physiological mechanisms that underlie the efficacy of psychological treatment are unknown. Some studies have included self-report measures other than pain diaries as part of the assess-

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ment battery and their findings suggest potential mechanisms related to the efficacy of psychological migraine treatments. Blanchard et al [7] found increased use of relaxation and physiologically based (eg, handwarming) coping strategies following treatment; however, these changes occurred both for participants receiving thermal biofeedback alone or with cognitive-behavioral treatment, as well as for subjects in a pseudomeditation control group. Sorbi et al [54] found that significant increases in problem solving and decreases in depressive self-statements occurred for both relaxation and stress-coping treatment groups. Similar changes have been found for stress [45] and depression [34]; unfortunately, the authors of these studies did not report if changes in coping strategies were related to improvements in headache. One study with adolescents reported that lower levels of avoidant coping were related to lower frequency (R* = 20%) and higher levels of active coping were related to shorter duration of migraine (RI = 19%) at 7 month follow-up [39]. It is unclear from the authors’ description, however, whether these relations reflect changes in coping or with baseline measures. Coping strategies appear to be a promising area for future research but few studies have examined how changes in coping are related to changes in headache activity.

CONCLUSIONS Biofeedback, relaxation, and stress-coping treatments have demonstrated effectiveness for migraine among adults, adolescents, and children. These treatments are effective for the majority of migraine sufferers, and treatment effects are reliably maintained for periods of at least one year. Despite their effectiveness, little is known about the mechanisms underlying treatment efficacy. Future research should explore this issue. Psychological treatments for migraine are effective for the majority of, but not all, individuals. Ways to enhance treatment effectiveness for individuals who do not demonstrate improvements in their migraine following psychological treatments are needed. We need to understand why effective psychological treatments for migraine are not widely used in clinical practice. One possibility is the lack of communication between psychologists who typically provide these services, and family physicians and neurologists who are most likely

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to diagnose migraine. Some migraine sufferers may be reluctant to seek psychological services due to the stigma attached to psychology and other mental-health related professions. These individuals may be more receptive to minimal-therapist contact interventions [5, 6, 10, 21, 34, 451. Increasing physicians’ awareness of these programs may also be helpful. Finally, psychological interventions require a significant investment of time and effort. Some migraine sufferers may not be interested in making this commitment, despite the proven efficacy of the treatments. ACKNOWLEDGMENTS Dr GJ Reid is supported by an lzaak Walton Killam Children’s Hospital postdoctoral fellowship and by an unrestricted grant from Bristol Myers Squibb to Dr PJ McGrath. The authors wish to thank Dr G Allen Finley and MS CT Chambers for their feedback on this manuscript.

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