From research to clinical practice: a systematic review of the implementation of psychological interventions for chronic headache in adults

Abstract

Background: Psychological interventions have been proved to be effective in chronic headache (CH) in adults. Nevertheless, no data exist about their actual implementation into standard clinical settings. We aimed at critically depicting the current application of psychological interventions for CH into standard care exploring barriers and facilitators to their implementation. Secondarily, main outcomes of the most recent psychological interventions for CH in adults have been summarized. Methods: We conducted a systematic review through PubMed and PsycINFO in the time range 2008-2018. A quality analysis according to the QATSDD tool and a narrative synthesis were performed. We integrated results by: contacting the corresponding author of each paper; exploring the website of the clinical centers cited in the papers. Results: Of the 938 identified studies, 28 papers were selected, whose quality largely varied with an average %QATSDD quality score of 64.88%. Interventions included CBT (42.85%), multidisciplinary treatments (22.43%), relaxation training (17.86%), biofeedback (7.14%), or other interventions (10.72%). Treatments duration (1 day-9 months) and intensity varied, with a prevalence of individual-basis implementation. The majority of the studies focused on all primary headaches; 4 studies focused on medication-overuse headache. Most of the studies suggest interventions as effective, with the reduction in frequency of attacks as the most reported outcome (46.43%). Studies were distributed in different countries, with a prevalent and balanced distribution in USA and Europe. Ten researches (35.71%) were performed in academic contexts, 11 (39.28%) in clinical settings, 7 (25%) in pain/headache centres. Interventions providers were professionals with certified experience. Most of the studies were funded with private or public funding. Two contacted authors answered to our e-mail survey, with only one intervention implemented in the routine clinical practice. Only in three out of the 16 available websites a reference to the implementation into the clinical setting was reported.

Non-Pharmacological Approaches to Headaches: Non-Invasive Neuromodulation, Nutraceuticals, and Behavioral Approaches

“…Behavioral treatments reduce stress, increase self-efficacy, and reduce the external locus of control. The combined effect of different factors could stimulate a change in the way patients perceive and experience pain, which in turn can lead to an improvement in symptoms [ 4 , 104 , 105 ]. At the biological level, these treatments seem to produce functional modifications in the brain areas and systems responsible for the perception and regulation of pain [ 4 , 106 ].…”

“…One of the barriers to the spread of these interventions is the need for neurologists or psychologists specialized in the use of behavioral techniques, which constitutes a cost, particularly if therapies are conducted individually and not in a group. Therefore, although there is much evidence of the effectiveness of behavioral approaches, these interventions are not widely used in clinical practice [ 105 ]. Moreover, the lack of a standardized treatment protocol in psychological treatment and the consequent diversity and heterogeneity of the specific protocols sometimes make it difficult to draw meaningful conclusions [ 104 , 107 ].…”

“…Two recent reviews describing different categories of behavioral treatments reported the efficacy of CBT in improving headache outcomes [ 4 , 105 ]: different studies using CBT with adults and children found a reduction in the frequency of headache [ 4 ] as well as significant improvements in patient-reported outcomes, including disability, self-efficacy, quality of life, medication intake, depression, stress and anxiety, pain catastrophizing, pain acceptance, and pain coping [ 4 , 105 ]. CBT is found to have greater benefits in patients who have concomitant psychological or environmental problems that play a role in triggering headache, such as work-related stress, mood disorders, or adjustment problems [ 19 ].…”

Exploring Emotional Distress, Psychological Traits and Attitudes in Patients with Chronic Migraine Undergoing OnabotulinumtoxinA Prophylaxis versus Withdrawal Treatment

“…The patients definite answer on receiving psychological strategies is a positive starting point to make complementary behavioral interventions available. In the literature, the recognition of the role of psychosocial aspects in migraine is increasing, with a definite interest in psychological approaches to be integrated with pharmacological and medical ones and a growing interest in, and utilization of, complementary and integrative strategies, such as mindfulness-based interventions [37,38,73]. However, a gap between research on the relevance and effectiveness of behavioral treatment interventions and the clinical practice remains [37,77,78].…”

“…The first-line management of CM is based on pharmacological treatment, according to the pathophysiology of the disturbance [ 11 ]. However, the bulk of literature is focused on improving the pharmacological outcome of this highly disabling disturbance through a multidisciplinary pathway of care [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. Psychological assessment and treatment for migraine should be integrated within this multidisciplinary approach early, to enhance adherence to pharmacological and non-pharmacological treatments and improve pain management, as in other neurological conditions causing chronic pain, as suggested by the Italian Consensus Conference on Pain in Neurorehabilitation [ 38 , 39 ].…”