Behavioral Treatment of Headache and Migraine Patients – Making Referrals

Why would I want to get behavioral treatment for my headaches?

There are quite a few reasons why a patient could benefit from seeing a psychologist. Of all these reasons, the most important is that 30-60% of all patients who use biofeedback, relaxation, or cognitive-behavioral therapy have many fewer headaches than before they started. Ultimately, the reason would be so that you have fewer headaches and get back to living life the way you want.

However, not everyone finds behavioral treatment useful. So, how do you know whether you and behavioral treatment are a good “fit”?

Here are some signs that you might benefit.
Do you have a hard time managing headache triggers, especially stress?

Stress is the most common headache trigger. Stress can cause a change in the brain that makes it more likely you will have a headache. Stress can also make a headache last longer and make it feel more painful. People who feel over-stressed also don’t do as well with the rest of their lives when they have a headache. This means that if you have a headache and are stressed, it is likely that the headache will have more of an impact on your life. This impact affects time with family/friends, things you do for fun, and work.

So should your goal be to avoid stress? No, because everyone experiences stress. Everyone, however, does not handle stress in the same way. Stress can’t be completely avoided. Learning to better deal with stress can help you have fewer headaches. This leads to less of an impact on your life.

Who might benefit? Patients who have depression and/or anxiety

People who have headaches and depression or anxiety feel like they are in a vicious cycle. Headaches may make a person feel more sad, worried, or anxious. When you are sad, worried, anxious, or frustrated, your chances of getting a headache are higher. In fact, research shows that people with migraine are between two to four times more likely to have depression and anxiety. So if you have this, don’t worry, you are not alone. This newsletter has an article that tells you more about the links between headache, depression, and anxiety.

Who might benefit? Patients who have problems taking medication as prescribed.

Providers do not limit behavioral treatment of headache to only those patients who have difficulty managing stress or experience depression, anxiety, or other mental health concerns. Many patients have trouble sticking to the medical treatment recommended. This leads to inadequate management of their headaches or migraines.

There are many reasons why people do not take headache or migraine medications:

Concerns about adverse side effects leads to a delay in taking medication in more than one in three. Feeling sleepy/tired was the most common and most bothersome side effect

Nearly 7 out of 10 want to wait to see if it really is a migraine

Nearly half want to take medications only if it is a severe attack

High cost is a reason in one in three for not refilling a headache medication

Patients hesitate to use a triptan when pain is mild due to limitations on pill quantity and reimbursements imposed by insurance companies

Weight gain or its possibility from preventive medications influence adherence

Safety concerns for pregnant women

Who might benefit? Other issues that can be treated with behavioral treatment

There are other issues in your life that can influence your headaches and their impact. These include problems with sleep, having a history of childhood abuse or neglect, or taking medication too often for your headaches. This newsletter contains other articles on sleep and abuse/trauma.

In terms of taking medication too often, how do you know if it’s too often? Have concern if you are taking any symptom relief medication more than 2 days a week. You may be overusing medication if you worry about having enough or hoard them. Talk with your health care team about your use of acute drugs. If using acute drugs too often, expect, even require your provider to create a plan on how to prevent overuse. Patients find that using behavioral treatments make this process easier and more successful.

How do I find a psycologist 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 behavioral medicine clinical services, or in private practice. Start by talking with your providers.

The next best referral sources are the American Headache Society membership and Find a Healthcare Professional search (will insert link to new public search directory on new site), the American Psychological Association Psychologist Locator Service (http://locator.apa.org).

State psychological associations and your health insurers’ list of mental health care providers may also be good sources. It is most helpful to search for psychologists who specialize in headache and/or pain management.

Should I talk with my provider about behavioral treatment?

There are misconceptions about the behavioral treatment of headaches. One is that meeting with a psychologist says that the pain lacks a physical cause. None of us wants an encounter that might suggest our pain is not real. Psychologists understand that there is a physical basis for headaches and migraines.

Psychologists are involved in the treatment of headaches and migraine because they know the pain is real. They can offer effective strategies for the management of this pain. They also know patients suffering from headaches or migraine many are in a vicious cycle. For the sufferer, it can be very helpful to discuss all this with someone familiar with pain. It is no misconception that pain is real and causes stress, tension, anxiety, or depression which in turn causes more pain.

Patients may incorrectly assume that seeing a psychologist for headache pain management means termination of the relationship with their medical provider. They may also think that a psychologist will not support the use of medications in the treatment of headaches or migraine. Psychologists who specialize in the treatment of pain are not against the use of drugs. They support a comprehensive, multidisciplinary, team approach.

When discussing a referral for behavioral treatment with your provider, you may wish to address the following points:

Let him or her know that you would like to work closely together on the treatment of your headaches or migraines. Express that you are the expert in understanding your body and your pain, and you would like to take an active role in self-management.

Share that you would like options to reduce the frequency, intensity, and duration of headaches. Indicate one or more of these tools are relaxation strategies and/or biofeedback.

Indicate you want to learn ways to manage your life to minimize the impact of headache pain or migraines on relationships, work, home chores, sleep, mood, stress and more.

Ask for referrals to licensed psychologists who specialize in the treatment of headache pain or migraines.

Ask this team of providers to share information with each other for your best care. This may involve phone conversations, e-mails when privacy is secure, and/or the sharing of medical records. You will need to sign consent forms to authorize the communication of your protected health information.

Find out if you have health insurance coverage for visits with a psychologist who treats headache patients by calling the member services number of your health insurer. This is typically found on the back of your health insurance card.

What should I expect from my first visit with a psychologist?

The psychologist wants to understand how headaches or migraine affects your life. He or she will ask questions about the history and nature of your headaches and migraines. There will be questions about past treatment attempts. There will be a focus on how headaches or migraines currently affect your work, relationships, home life, and leisure activities. The provider may ask you to fill out some questionnaires in advance to best understand you.

Cognitive-behavioral therapy (CBT) teaches how to recognize and cope with stress. It helps to understand how thoughts and behaviors affect symptoms. CBT helps to understand how to change the way the body responds to anticipated pain. You and the psychologist or behaviorist will set specific treatment goals together. The chief goal is to exchange sick time for wellness time. You can spend the exchanged time enjoying yourself, staying healthy, managing triggers and stress, thereby minimizing headaches/migraines.

Treatment may focus on any or all of the following:

Wellness Activities (Healthy Sleep, Physical Activity and Eating)

Relaxation Strategies and Stress Management Techniques

Managing Headache Triggers

Modifying Thoughts to Make Them More Adaptive and Beneficial

Pacing of Activities

Behavioral treatment is meant to empower you to act in your own best interests. Choosing comprehensive treatment helps you manage the difficulties in the many areas of your life that have been influenced by headache or migraine. If you are ready to approach the management of your headache or migraine in a new way, pursue behavioral treatment.

Lucy Rathier, PhD, Behavioral Medicine Clinical Services, The Miriam Hospital; Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Providence, RI

Biofeedback and Relaxation Training for Headaches