Donald B. Penzien

Behavioral treatment strategies for migraine and tension-type headache: a review of the evidence and future directions

Behavioral treatments have become widely accepted interventions for migraine and tension-type headache. Ample empirical evidence supports the effectiveness of interventions, such as relaxation training, biofeedback and cognitive–behavioral (i.e., stress-management) treatments. Such interventions may be utilized alone or in combination with the more widely used pharmacological treatments for headache. Behavioral approaches are often the treatments of choice for patients who have contraindications to or who are refractory to traditional pharmacologic interventions. Recent research has attempted to increase the availability of behavioral treatments to patients through more cost-effective forms of treatment administration. Ample empirical evidence now indicates that these efficient interventions are just as effective as more time-intensive, individually administered clinic-based treatments. Important future directions for behavioral headache treatments include: integration into the primary care setting, developing algorithms for matching behavioral and pharmacologic treatments to patient characteristics for maximum effectiveness, behavioral skills training to enhance outcomes with pharmacologic interventions and reduce complications (e.g., rebound migraine), as well as identifying and treating comorbid conditions that undermine treatment.

Sleep and Quality of Life in Headache and Migraine

Headache and sleep disorders are prevalent, comorbid conditions that challenge physical as well as psychosocial well-being. Headache is the most common pain-related complaint and the seventh leading ailment seen in medical practice, accounting for 18 million physician visits annually in the USA alone (1). Though historically headache often has been trivialized (perhaps because pain is not easily quantified and headache does not generally compromise life expectancy), headache is in a major quality of life (QOL) concern. In fact, migraine headache is among the 20 leading causes of “years lived with disability” according the World Health Report (2). The burden of headache is increasingly appreciated in psychological, family and interpersonal, vocational, and economic realms. Headache, particularly in its more chronic and severe forms, has been linked to sleep disorders. Interestingly, the sleep disorders associated with headache are varied in nature, including obstructive sleep apnea, periodic limb movement disorder, circadian rhythm disorder, insomnia, and hypersomnia. General symptom patterns, particularly morning headache and chronic daily headache, are suggestive of and aid in recognition of a sleep disorder. Management of the sleep disorder may improve or resolve the headache; sleep-disordered breathing is the most empirically supported example of this relationship. Although pure sleep-related headaches, such as hypoxemia-related headache, are less prevalent and more easily recognized, primary headaches as well are often impacted to some degree by sleep. Irrespective of sleep disorders, variation in the sleep/wake schedule is one of the most common acute headache precipitants while sleeping is one of the most common palliative responses to headache. Insomnia is the sleep disorder most often cited by clinical headache populations. Despite an emerging literature supporting the interdependence of sleep and headache, our understanding of the underlying mechanisms remains speculative. Few well-controlled studies are available, and it is difficult to generalize results across sleep and headache literatures due to inconsistencies in diagnostic nosologies, lack of standardized outcome measures, and varied populations. Future research with improved methods is needed to identify mediating factors between sleep and headache. This chapter reviews the co-morbidity of headache and sleep disorders, prevalence, diagnostic considerations, societal and individual burden of headache, clinical implications, and considerations for future directions.