Trends in the Management of Headache

The Authors’ Reply—We thank Dr. Solomon for his interest in our study assessing national trends in headache management and for raising important questions about the usefulness of lifestyle modification counseling. As noted, we found a decline in first-line recommended lifestyle modification counseling for headache over the past decade, contrary to prominent headache guidelines.¹ For instance, guidelines from the American College of Physicians suggest that physicians encourage their patients to identify and avoid specific dietary, behavioral, and environmental triggers for migraine headache.²

While he is correct in pointing out that generic advice on improving diet and exercise habits may lack rigorous scientific evidence showing reduced headache frequency, the dietary and lifestyle counseling provided during a headache visit would likely be targeted towards specific factors that trigger headache. Moreover, we do not agree that “increased stress, dehydration, lack of sleep, sedentary lifestyle, and poor diet… have not been scientifically linked to increased migraine frequency.” In fact, evidence suggests the opposite: migraine headaches are frequently triggered by stress, sleep deprivation, or dietary choice, in addition to a wide array of lifestyle and environmental factors.³

Finally, as we discuss in our paper, our measure of counseling is not limited to diet and exercise counseling. Another important component of our variable includes mental health counseling and stress management therapy, which as Dr. Solomon notes has been shown in various forms to improve headache symptoms in systematic reviews and randomized controlled trials.^4,5