Behavioral and nonpharmacologic treatments of headache

Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency-severity, analgesic/abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for cognitive-behavioral treatment of headache disorders. Controlled studies of cognitive-behavioral therapies for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of approximately 50%, roughly equivalent to propranolol. Patients with chronic daily headache (CDH) are more likely to overuse symptomatic medication (and in some cases abuse analgesics) and have more psychiatric comorbidity and functional impairment and disability. They are at least as likely to experience stress-related intensification of headache as those whose episodic headaches occur less than 15 days a month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment as a solo modality without concomitant prophylactic medication than is the case for episodic tension-type headache and migraine sufferers. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations.