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BEHAVIORAL MEDICINE FOR CHRONIC HEADACHE: OVERVIEW AND PRACTICAL TOOLS FOR THE PRACTICING PHYSICIAN

Lake, Alvin E. III

CONTINUUM: Lifelong Learning in Neurology: December 2006 - Volume 12 - Issue 6, Headache - p 235-258
doi: 10.1212/01.CON.0000290513.57505.b2
Article

There are multiple reasons to justify the inclusion of behavioral medicine in headache management. Research identifies stress as a prevalent headache trigger or aggravator. The use of direct questions, headache diaries, and behavioral analysis can help identify relevant stressors. Stress management therapies consistently yield from 35% to 55% headache improvement over baseline and, when combined with appropriate medication, provide a synergistic effect. Smoking cessation and aerobic exercise can help. Use of compliance-enhancement techniques can improve adherence to both medical and behavioral treatment recommendations and may improve clinical outcomes. Behavioral factors play an important role in complex cases of medication-overuse headache. The addition of behavioral therapy (eg, biofeedback and nonpharmacological coping skills) can help reduce the high rates of relapse after drug withdrawal. Attention to psychiatric comorbidity, using focused empathic interview techniques, brief psychometric screens (eg, Beck Depression Inventory II), and patient checklists (Primary Care Evaluation of Mental Disorders [PRIME-MD]) can help the physician employ treatments that address both headache and relevant psychiatric conditions, increase patient satisfaction, and improve outcomes. Personality disorders are often comorbid with severe chronic daily headache conditions and complicate treatment. Appropriate therapeutic responses to behavioral red flags (the "hug" sign, entitlement expectations, pseudocoping, covert narcotic requests, "sincere" but disingenuous behavior, inappropriate underlying anger, problematic family issues) can keep headache treatment on a productive path. Simple communication guidelines can help reduce dysfunctional pain-related family behavior. Behavioral medicine referrals for biofeedback and stress management therapy can be useful in straightforward cases and should be a requirement for challenging patients and severe forms of chronic daily headache.

© 2006 American Academy of Neurology
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