Integrating headache trigger management strategies into cognitive-behavioral therapy: A randomized controlled trial.

Abstract

Objective: Traditionally, the standard advice to individuals suffering from migraine and tension-type headache was that the best way to prevent headaches is to avoid the triggers. This advice has been challenged in recent years and the Trigger Avoidance Model of Headache has been proposed, which suggests that one pathway to developing a headache disorder is by avoiding triggers resulting in trigger sensitization. The objective of the study was to evaluate a novel intervention for primary headache comprising a new approach to trigger management that includes exposure to some triggers with the goal of trigger desensitization (learning to cope with triggers [LCT]) integrated into a cognitive-behavioral therapy (CBT) program (LCT/CBT). Method: The study was a randomized controlled trial comparing LCT/ CBT to the same treatment program but using the traditional approach to trigger management of encouraging trigger avoidance (avoid/CBT), and to a waiting-list/treatment-as-usual control condition (WL/ TAU). Adults suffering from primary headache (88 female/35 male) were allocated to the three conditions. Results: The three groups significantly differed from baseline to posttreatment on the primary outcome measure of attack frequency, and LCT/CBT significantly differed from WL/TAU but Avoid/CBT did not. Similar results were obtained on the secondary outcome measures, and treatment gains were maintained at 4-and 12-month follow-up. Conclusions: The results suggest the value of using LCT as a component of a CBT program but were not conclusive as the direct comparisons between the two treatment conditions failed to reach statistical significance. The findings support a study of LCT/CBT with a larger sample.

Avoid or seek light – a randomized crossover fMRI study investigating opposing treatment strategies for photophobia in migraine

“…No effect of study phase was found for headache frequency and severity or ictal photophobia, probably due to the high variability in the patients’ treatment responses. In the LCT approach, the trigger exposure treatment was conducted for 8 weeks and completed with cognitive-behavioral and relaxation techniques [ 13 , 15 ]. With only one week, the duration of the interventions was probably too short to produce significant clinical improvements in the current investigation.…”

“…Trigger exposures were accompanied by several methods of cognitive-behavioral therapy (education, management of dysfunctional thoughts, relapse prevention strategies) and relaxation training. When compared to an untreated waiting list, patients with recurrent headaches receiving LCT showed reduced headache and medication consumption, whereas for trigger avoidance combined with cognitive-behavioral therapy no effect was found [ 13 , 15 ].…”

“…Indeed, prolonged exposure to noise [8,9], visual stimuli [10,11] and stress [12] resulted in decreased nociceptive responses. Martin et al suggested the behavioral management concept 'Learning to Cope with Triggers' (LCT) as preventive strategy [6,[13][14][15]. Here, triggers that were potentially harmful, e.g., hunger, dehydration or lack of sleep, should be avoided, but for other triggers, such as flicker or noise, prolonged exposure was used.…”

Do behavioral treatments work for migraine prevention?

“…The outcomes of behavioral treatments have been shown to differ by type of treatment. For example, cognitive behavioral therapies lead to reductions in attack frequency and disability, [3][4][5][6] whereas mindfulness-based therapies have usually reduced only disability (with one recent exception, which included a four-session migraine-focused behavioral intervention). [7][8][9] Even within a modality, such as CBT for depression, effect sizes become larger as therapist interaction increases.…”

Behavioral Health, Telemedicine, and Opportunities for Improving Access

“…Cognitive factors, such as fear and avoidance of pain and pain catastrophizing, have demonstrated strong relationships with pain interference and quality of life [ 6 – 8 ]. Interventions that focus on identifying and restructuring maladaptive pain cognitions have demonstrated efficacy in improving pain-related quality of life [ 9 – 12 ]. Incorporating behavioral management of chronic pain and headache disorders improves outcomes beyond medical management alone [ 13 – 15 ].…”