Table 1.

Potential problematic attitudes and beliefs towards nonpharmacological intervention and possible interventions¹⁴

Nonpharmacological Interventions	Patient Attitudes and Beliefs	Possible Interventions
Relaxation Training	Patient upholding negative self-statements (e.g., I cannot relax and this technique won’t help me!”).	Use cognitive behavioral techniques (CBT) to help patient identify and modify these maladaptive/irrational thoughts.
	Overly worried about his/her performance and upset that performance is below expectations.	Assist patient with establishing realistic goals. Indicate that he/she is trying too hard. May want to incorporate mental imagery or other mindfulness techniques to help patient to be in a more tranquil and “passive” state.
	Concern about losing control and being alert.	Discuss patient’s concerns about losing control. Provide education about how relaxation training can help patient proactively control/manage stress and headache.
Biofeedback Training	Tries to make changes in biofeedback signals, but without success.	Encourage patient not to focus too much on the signal and output. Reassure patient that the training is a learning process and he/she will be able to do so gradually.
	Perceives the task as a challenge rather than a tool to help him/her to relax.	Educate patient how a competitive attitude can be counterproductive. Encourage patient to adopt a more passive approach
	Concern and anxious about not being able to produce a desirable response on the signal.	Assess patient’s expectations. Provide reassurance and reinforcement that with practice, he/she will be able to obtain a realistic and desirable outcome. If patient experiences evaluation anxiety, consider allowing patient to complete the training without the presence of the therapist.
Stress Management Training	Minimizes or unaware of the importance of this topic.	Provide education about how stress can exacerbate headache.
	Lack of self-confidence in managing headache and stress.	Discuss the concept of locus of control and self-efficacy. Utilize CBT techniques to address any maladaptive beliefs of his/her ability. Empower patient to build-up confidence by practicing stress management techniques in between sessions and examine the actual and possible outcomes. Provide positive reinforcement.
Trigger Management	Overwhelmed by the numbers of triggers.	Assist patient with prioritizing his/her triggers based on saliency. Also, ask patient to utilize a headache diary to explore patterns over time.
	Lacks self-confidence to manage triggers.	Encourage patient to identify the triggers that are most amenable to changes and work on 1–2 triggers at a time. Provide positive reinforcement and ensure that patient documents and identifies his/her progress to increase self-confidence. Also, provide more structure to minimize failures.

Used by permission from Headache by Todd A. Smitherman, Donald B. Penzien, Jeanetta C. Rains, Robert A. Nicholson, and Timothy T. Houle, ISBN 978–0-88937-328-0

©2015 Hogrefe Publishing www.hogrefe.com