Headache Types. Behavioral Treatments of. Tension Headache. Migraine Headache. Mixed Headaches. TMJ Disorder. Tension Migraine.

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1 Headache Types Behavioral Treatments of Migraine Headaches Jonathan D. Cole, Ph.D. Clinical and Health Psychologist Bluegrass Health Psychology Lexington, KY Tension Migraine Mixed Cluster TMJ Tension Headache Occurs outside the skull Muscles outside the skull contract and pinch nerves between the muscle and skull Long term muscle contraction produce lactic acid Very sensitive to stress Migraine Headache A vascular headache An inflammation of blood vessels inside and outside the brain Often a throbbing pain Is hereditary Light and sound sensitivity Unsure the true cause Mixed Headaches Combination of Tension and Migraine Headaches TMJ Disorder Pressure from on the TMJ Can be from teeth grinding Can trigger a migraine or tension headache Can trigger a migraine or tension headache Stress related 1

2 Migraine Triggers (Kelman, 2007) Stress (79.7%) Hormones in women (65.1%) Not eating g( (57.3%) Weather (53.2%) Sleep Disturbance (49.8%) Odors (43.7%) Neck Pain (38.4%) Light (38.1%) Migraine Triggers (Continued) Alcohol (37.8%) Smoke (35.7%) Sleeping Late (32 %) Heat (30.3%) Food (26.9%) Exercise (22.1%) Sexual Activity (5.2%) Headache Medication Vaso-Constrictors Muscle Relaxers Narcotic Medication Over the Counter Medication Anti-Seizure Medications Rebound Headaches Taking daily doses of narcotic, aspirin, Tylenol, or barbituates Makes headaches worse and more frequent Majority of chronic daily headaches are a result of rebound headaches Psychological Headache Assessment Frequency, intensity, location, and type of headache Any recent change in symptoms Neurological evaluation? Relationship with headache and stress Other medical conditions (IBS, Seizure disorder) Headache Assessment (Cont) Headache medications Aspartame/MSG use Alcohol/ Drug use g Sleep Assessment (Insomnia, Apnea, ect) Stress Psychiatric status (depression, anxiety, PTSD, ect.) Secondary Gain (no school, work, attention) 2

3 Things you can do for Headaches Avoid Aspartame/ NutraSweet Limit Alcohol Improve sleep No daily pain medication Watch diet Behavioral headache treatment Behavioral Headache Treatment Relaxation Training Biofeedback Cognitive-Behavioral Therapy Autonomic Nervous System Relaxation Training Sympathetic Nervous System Fight or Flight Muscle Tension GI Irritation Decrease Peripheral Blood Flow Heart Rate and Body Temperature Increase Parasympathetic Nervous System Decrease Muscle Tension Calms GI Tract Increase in Peripheral Blood Flow Heart Rate and Body Temperature Decrease Teach how to activate parasympathetic nervous system Include hand warming imagery if migraine Better if taught in person Encourage practicing Perform right when headache comes on for best results Types of Relaxation Progressive muscle relaxation Autogenic relaxation passive PMR (no tensing) Stretch relaxation Imagery Imagery relaxation Use all senses, smell first, touch, sound, then sight For hand warming try lying on the beach with hands and feet in warm sand or warming hands and feet in front of a fire in a cabin in the woods 3

4 Biofeedback Works best if used in conjunction with relaxation EMG measures surface tension to train muscle relaxation, reducing tension Thermal teaches to increase hand temperature, increasing blood flow to periphery, reducing tension from migraine EMG Biofeedback Sites for Headaches Frontalis forehead (horizontal) Cervical paraspinal neck (vertical) FnP (Schwartz technique) one forehead and one cervical paraspinal lead on the same side (for occipital headaches) Masseter - Jaw (Vertical) Trapezius tops of shoulder (vertical) Thermal biofeedback Can use a finger tip thermometer before and after relaxation with hand warming Use same finger for post test that was used for the pre-test Try to get temperature to 90 degrees F or above Behavioral Relaxation autonomic self regulation Increase pleasurable activities Decrease avoidance behaviors Reward positive behaviors Develop new stress and anger management strategies 13 year old female with daily headache, with intermittent severe pain Taught relaxation training with hand warming Performed thermal biofeedback Provided cognitive therapy to reduce stress response Patient increased her hand temperature by 15 degrees Patient eliminated severe headaches Patient eliminated severe headaches Patient reduced severity of daily headaches 4

5 Behavioral Headache Treatment Outcomes (Rains, Penzien, et al 2005) Meta-analysis indicated behavioral interventions consistently yield 35% to 55% improvement in migraine and tension headaches Effective with pediatric headache Can be used in conjunction with medication Organizations Endorsing Behavioral Headache Interventions American Academy of Family Physicians American Academy of Neurology American Headache Society American College of Physicians American Medical Association Canadian Headache Society National Institutes of Health National Headache Foundation World Health Organization Why is this not used? Biofeedback reimbursement only until recently have new codes been available Limited number of trained psychologist Patient resistance to seeing a shrink / it s in my head but it s not in my head Sleep Disorders Affecting Headache Sleep Apnea Restless Leg Syndrome/ Periodic Limb Movement Bruxing/ Night time teeth grinding Insomnia PAP Desensitization Training patients to tolerate the CPAP mask Takes an average of 3 sessions with 92% success Teaches how to relax while wearing the mask Bruxing/ Night time Teeth Grinding When person grinds or clenches teeth when asleep Can bite down times harder when asleep Can put pressure on the TMJ causing pain p p gp Can trigger a headache Can damage teeth Stress makes this worse Bite Guard treats this CBT helps 5

6 How Insomnia Becomes Chronic: The 4-Factor Model Insomnia Indirect Target for CBT Treatment Problems going and / or staying asleep Addresses sleep onset and sleep maintenance Can exacerbate headaches Direct Target for CBT Treatment Insomnia Threshold Pre- mo rb id A cut e Early C hronic Short Term Lo ng T erm Predisposing Precipitating Perpetuating Conditioned Arousal CBT Treatment of Insomnia Address irrational beliefs about sleep Improve sleep hygiene Sleep restriction (should not be done for seizure or bipolar disorders) Improve sleep efficiency Eliminate sleep medication (benzodiazepines, Ambien, ect.) CBT with Insomnia Outcomes Found more effective than Ambien short and long term Found more effective than Lunesta short and long term CBT Insomnia Treatment for Headaches (Calhoun, 2007) Behavioral sleep treatment given to patients with transformed (chronic daily) migraine 48% of the patients reverted back to episodic migraines with just treating the sleep component 29 year old female with recurrent migraines and primary insomnia Taught relaxation and hand warming Taught relaxation and hand warming Taught basics of sleep and sleep hygiene Addressed irrational thoughts regarding sleep Restricted sleep to 6 hours a night 6

7 4 week follow up patient has had no migraine episodes Patient is sleeping through the night and has increased sleep to 7 hours Sleep efficiency increased from 60% to 95% 50 year old male with daily migraine headaches and sleep apnea Was having difficulty tolerating his CPAP Was taking in large amounts of diet soda per day Taught CPAP Desensitization Taught relaxation and hand warming imagery Had him stop his Aspartame use 6 week follow up found no daily migraine with one migraine in the past 4 weeks Patient was tolerating his CPAP for 7 hours per night Was feeling well rested the next day Why has this not been used Limited psychologists trained Not a quick fix Pharmaceutical companies have larger advertising budget Conclusion Behavioral treatments of headaches are a viable treatment Sleep disturbance exacerbates headaches Treating the sleep disturbance often reduces headaches Behavioral treatments of insomnia more effective than medication and can reduce headache severity 7