Using Cognitive Behavioral Therapy Techniques to Treat Migraine

Abstract

Migraine is a common and disabling neurologic disorder that often occurs alongside anxiety and mood disorders. Information is provided on the biological basis of the disorder, the interactive effects of co-morbidity, and common psychological distortions manifested by individuals with migraine. Psychological treatments based on cognitive behavioral techniques have demonstrated efficacy to treat migraine. Migraine treatment can be incorporated in private practice and integrated care settings.

Kate, a pleasant 30-year old corporate administrator, scheduled an initial appointment because of reported symptoms of intense anxiety that interfere with her ability to work. The symptoms of include difficulty concentrating, blurry vision, nausea (with occasional vomiting), and throbbing head pain. During the intake, she describes sudden onset of symptoms that often result in her having to leave work. She reports anticipatory anxiety around these attacks, and she states she has significantly altered her day-to-day routine to attempt to reduce the likelihood of these attacks. As you explore the events that precede the “attacks,” you question whether these are panic attacks. Might they be migraine headache attacks? If so, how should you best help Kate?

Incidence and Prevalence of Migraine

You almost certainly have patients with migraine currently in your practice, whether they are talking about it or not. Migraine is very common: 18% of women and 6% of men in the United States have migraine (Lipton et al., 2007). Migraine is ranked sixth in specific causes of years lived in disability, higher than any other neurological disease (Steiner et al., 2015). Migraine is most prevalence in women aged 18–45. Migraine symptoms peak during the most potentially productive years of life for the majority of our patients (Lipton et al., 2007). Migraine is also more common among people with mood and anxiety disorders. Migraine interferes with people’s ability to go to work and school, and productivity at work or school even when present (Steiner et al., 2015).

Migraine is a chronic disease with episodic symptom manifestations. People with migraine typically are symptom-free most of the time. However, they may also live in constant fear of the next debilitating attack of painful neurologic symptoms. People with migraine can fall into catastrophizing thought patterns, or patterns of fear and avoidance, that lead to considerably restricted daily activities and reduced quality of life. Further, lifestyle factors such as changes in stress, poor sleep, and skipping meals are associated with the onset of migraine attacks.

Nature of Migraine

Migraine is not “just a headache.” Rather, migraine is a neurological disorder characterized by attacks of severe, unilateral, pulsing head pain and associated symptoms of nausea/vomiting and extreme sensitivity to light and sound (Headache Classification Committee of the International Headache Society, 2013). Migraine attacks consist of three phases: a premonitory phase (or “prodrome”), headache phase, and postdrome phase. During the premonitory phase, people with migraine may experience a wide range of neurologic symptoms for minutes to hours preceding head pain, including yawning, thirst, nausea, difficulty with thinking/concentration/language, or unusual sensitivity to sensory stimuli including light, sound, smell, and touch. Approximately 20% of people with migraine also experience aura, a specific sensory disturbance that often manifests as zig-zag lines, spreading dark spots, or flashing lights that spread across the patient’s visual field. During the headache phase, the person with migraine experiences head pain and associated symptoms. During the postdrome phase, a person with migraine may experience residual neurological symptoms such as sensitivity to sensory stimuli, and are at a heightened risk for migraine recurrence for 24 hours.

Migraine is also emotionally distressing, as attacks are unpredictable and highly disabling. As migraine attack frequency increases, associated burden increases. Most people with migraine have fewer than 14 headache days in a month. This is called “episodic migraine.” However, a small portion of people with migraine (2% of the overall population) have headaches on 15 or more days per month (“chronic migraine”). Chronic migraine is associated with increased burden in every domain -- occupational, educational, social role functioning, and emotion functioning.

Medical Treatment of Migraine

Not all headaches are migraine attacks. Headache symptoms can be indicative of a significant medical event. Therefore, migraine should be diagnosed by a physician, typically a primary care provider or neurologist. Migraine treatment has two goals: to treat each migraine attack (acute treatment), and to reduce migraine frequency (preventive treatment). Treatment options include medication and psychological interventions.

The vast majority of people with migraine use acute medication to treat individual migraine attacks. Recommended medications include migraine-specific medications (triptans or ergotamine) and non-steroidal anti-inflammatories (Holland et al., 2012). Acute medications are most effective for migraine when taken early during the attack. Not all migraine attacks are easy to identify early on, and nausea/vomiting can make taking oral medication difficult. Therefore, people with migraine may have several medications. However, overuse of medications (>10 days/month for migraine-specific medications or using a combination of medication, > 15 days/month when using non-steroidal anti-inflammatories alone) is associated with medication overuse headache, a secondary headache disorder thought to be caused by the frequent use of these medications in people with migraine (Headache Classification Committee of the International Headache Society, 2013). Therefore, people with migraine have a challenging balance for medication adherence: treat early, but do not overuse. For this reason, psychologists often focus on optimizing a patient’s medication adherence in early phases of migraine treatment. Common preventive migraine medications include beta-blockers, anti-epileptic medication, and tricyclic antidepressants. Botulinum toxin may also be used for chronic migraine.

Relaxation, biofeedback, and stress management/cognitive behavioral therapies have demonstrated strong empirical support for the preventive treatment of migraine (Singer, Buse, & Seng, 2015). For example, in the Treatment of Severe Migraine Trial (NCT00910689), following a 5-week acute medication optimization run-in, 232 people with migraine (3–20 migraine days/month) were randomized into a 2 [Behavioral Migraine Management (BMM) vs. No BMM] X 2 (Preventive Medication vs. Placebo) factorial treatment design for 4 months, after which they were followed for 12 months (Holroyd et al., 2010). BMM is a comprehensive psychological migraine treatment protocol including relaxation, trigger and migraine attack management, cognitive behavioral stress management and/or biofeedback. BMM was delivered through 4 monthly in-person sessions, 3 interim phone calls, and a patient manual and audio lessons. Preventive medication (beta-blocker) dose was adjusted for 4 months and continued through the follow-up period.

For the primary outcome of migraine days (evaluated by daily diary), participants who received BMM or Preventive Medication alone experienced a greater reduction in migraine days than placebo; however, participants who received a combination of BMM and Preventive Medication experienced the largest reductions in migraine days compared to all other groups (Holroyd et al., 2010). However, when evaluating headache-related disability (Headache Disability Inventory; Jacobson, Ramadan, Aggarwal, & Newman, 1994), people randomized to receive BMM experienced larger reductions in headache-related disability than people who did not receive BMM (Figure 1). Results from this influential trial suggest that a combination of psychological treatment and preventive medication may result in the largest reduction in migraine symptoms (days/month), but that psychological treatment in particular is helpful for reducing migraine-related disability. For this reason, psychologists in headache settings are often asked to evaluate and treat people with migraine who experience high rates of disability.

Figure 1.

Changes in the Headache Disability Inventory during the Treatment of Severe Migraine Trial.

Behavioral Targets in Migraine

People with migraine have brains that are much more sensitive to changes in their environment than people without migraine (Burstein, Noseda, & Borsook, 2015). In colloquial parlance, changes in the environment that precipitate migraines are often referred to as migraine “triggers.” It is important to note that triggers do not “cause” migraine attacks. Rather, triggers are homeostatic disruptions that increase the likelihood a migraine attack will occur. Certain common migraine triggers are not amenable to behavior modification, such as hormones and weather. However, other common migraine triggers are amenable to change, and often serve as the behavior change targets in cognitive behavioral therapies for migraine.

Stress is the most commonly cited migraine trigger. Daily diary evidence suggests that both increases and decreases in stress are associated with an increased likelihood of migraine (Houle et al., 2012). In other words, it appears that the change in stress is particularly problematic for people with migraine. For example, a person with migraine may describe frequently experiencing migraine attacks on particularly high stress days at work, as well as on the first day of vacation. Keeping stress consistently low is critical for people with migraine.

Poor sleep quality and low sleep hours are also common migraine triggers. Daily diary evidence suggests that poor sleep quality independently increases likelihood of migraine, and interacts with stress such that a high stress, poor quality sleep day has the highest likelihood of migraine (Houle et al., 2012). Migraine attacks themselves can also interrupt sleep, exacerbating the cycle of migraine attacks.

Many people with migraine describe specific food triggers. However, both retrospective surveys and food deprivation studies demonstrate that the most important food-related trigger is skipping meals (Wober & Wober-Bingol, 2010). In fact, one recent study suggested that nighttime snacking may be protective against migraine attacks, providing further evidence that fasting is a potent migraine trigger (Turner et al., 2014). Dehydration has also demonstrated an association with migraine onset. This is particularly important for people with migraine who have limited control over eating and hydration schedule, such as students and people working as operating heavy machinery or working on a retail floor.

Caffeine and alcohol are associated with secondary headaches in those without migraine (e.g., caffeine withdrawal and hangover), and they also have been identified as potential migraine triggers. However, the evidence about caffeine and alcohol is not as strong as the evidence for skipping meals. Other food triggers commonly reported by people with migraine have insufficient/mixed empirical evidence, including chocolate, amine-containing foods, certain fruits and vegetables, aspartame, and monosodium glutamate (Wober & Wober-Bingol, 2010). Therefore, focusing on the behavioral targets of frequently eating small healthy meals and staying hydrated are likely more useful for more people with migraine than “elimination diets.”

Cognitive Targets in Migraine

Migraine attacks are unpredictable and highly disabling. People with migraine are often encouraged by their friends, family, and medical providers to identify their specific triggers, and then to avoid those triggers in an attempt to reduce migraine frequency. Although this can be a useful strategy for empirically validated triggers, individuals with migraine are unlikely to identify novel individualized migraine triggers even using natural experimentation and careful diary monitoring (Houle & Turner, 2013). Thus, this approach (without professional monitoring) can have the paradoxical effort of contributing to a fear-avoidance cycle, which is well-established in the musculoskeletal pain literature.

The individual with migraine may develop (potentially inaccurate) beliefs about potential migraine triggers. This may lead to fear and avoidance of these potential migraine triggers, withdrawal from everyday activities associated with these potential triggers, increasing disability, stress, and the likelihood of future migraine attacks. Indeed, fear of pain is associated with increased migraine-related disability (Black, Fulwiler, & Smitherman, 2015), and mere trigger avoidance appears to be a suboptimal strategy for migraine management (Martin et al., 2014). Psychologists are well-positioned to understand the psychological and behavioral patterns that exacerbate migraine.

Catastrophizing is a maladaptive cognitive style characterized by focusing on the worst possible outcomes of a given situation. Common migraine related catastrophizing thoughts might include, “I have a big meeting today; I just know I’m going to get a migraine and ruin it!” or, “If I take my migraine medication at work, my boss will know that there’s something wrong with me and I will get fired.” Catastrophizing is a critical component of the fear-avoidance cycle. Higher catastrophizing has been associated with more severe migraine symptoms and increased disability and impairments in quality of life; further, cognitive behavioral migraine treatment approaches that reduce catastrophizing have demonstrated large effects on reductions in migraine symptoms and migraine-related disability (Thorn et al., 2007).

In migraine, self-efficacy refers to confidence in one’s ability to use migraine management strategies effectively. Self-efficacy is a construct used in a variety of psychological theoretical models because of its strong relationship with behavior change. In migraine, higher self-efficacy has been associated with lower disability and maladaptive headache-related beliefs (French et al., 2000). Self-efficacy is behavior specific; therefore, in migraine, self-efficacy can refer to confidence to use lifestyle management strategies such as stress management, and can refer to confidence to adhere to medication regimen. Cognitive behavioral migraine interventions that improve self-efficacy have demonstrated efficacy to reduce migraine symptoms and disability (Holroyd et al., 2010).

Psychological Treatment of Migraine

Typical psychological treatment of migraine begins with a detailed assessment of migraine history, comorbid psychiatric and medical conditions, and family history. Current preventive and acute migraine management strategies should be assessed. The psychologist will also assess perceived triggers and any patient perceived patterns in migraine activity. While in therapy, the majority of people with migraine will be asked to keep a headache diary. This serves two purposes: initially, to ensure accurate diagnosis and assessment of pre-treatment migraine management strategies and triggers, and later to track changes in target behaviors, migraine days, and migraine-related disability. For patients with psychiatric comorbidity, psychologists may also want to track variation in depressive or anxious symptoms along with migraine symptoms to observe their co-variation.

Providing a strong therapeutic rationale is critical for engaging patients with migraine in behavioral treatment. Patients with migraine experience significant stigma in their daily lives and could experience the referral to a psychologist for migraine treatment as dismissive of migraine symptoms (Seng & Seng, 2016). It is critical to communicate to the patient that you do not believe their migraine attacks to be psychogenic in nature, and that migraine is not their fault. Education should center around the fact that migraine is a neurologic disease characterized by episodic attacks; for people who have this disease, attacks can be precipitated by a variety of factors, some of which are not in under our control (e.g., weather), and some of which are at least partly under our control (e.g., stress). Psychological treatment of migraine will focus on managing precipitants that are under our control.

Variations in stress are such a common migraine precipitant that most behavioral migraine treatment protocols begin with a stress management component (Singer et al., 2015). The goal is to engage in stress management every day to keep stress consistently low. Basic relaxation response strategies such as deep breathing, progressive muscle relaxation, autogenic training and imagery can be used to reduce migraine. Biofeedback, alone or in combination with other behavioral treatment strategies, has also demonstrated efficacy to reduce migraine symptoms and disability. Biofeedback can be particularly useful in patients who lack autonomic awareness, who find relaxation strategies challenging, or for whom a concrete example of how their mind influences their body increases belief in the rationale of behavioral migraine treatment.

Behavior change is the second major component of cognitive-behavioral treatments for migraine management. In clinical practice, providers should tailor the behavior change interventions to those behaviors which are most problematic for each patient. Typically, medication adherence is a core component of any behavioral migraine treatment (Rains, Penzien, & Lipchik, 2006). Almost all people with migraine will take at least one (but possibly many) acute migraine medication(s). Psychologist can use behavioral strategies to facilitate patient adherence to recommendations regarding acute medication, such as taking migraine specific medication early during an attack and avoiding medication overuse. Common strategies include helping patients identify their individual early migraine warning signs (premonitory symptoms), keeping medication on hand when migraine attacks may occur, and tracking medication taking. Psychologists frequently use behavior change strategies to help patients with migraine keep a consistent eating schedule, avoid dehydration, and limit caffeine and alcohol intake. Psychologists may also use components of cognitive behavioral therapy for insomnia, sleep hygiene, stimulus control, and sleep restriction to help patients with migraine regulate sleep (Smitherman et al., 2016).

When using a cognitive treatment model, psychologists may directly address maladaptive cognitions related to the fear-avoidance cycle in migraine. For example, psychologists may reframe catastrophizing cognitive patterns to assist patients with migraine identify more adaptive ways of interacting with their day-to-day stressors. Many behavior change goals (reducing stress, improving sleep, medication adherence) can be facilitated through directly addressing maladaptive cognitive patterns that may interfere with successful engagement in the behavior.

Unless contraindicated or not preferred, the majority of people with migraine should take acute medication to manage migraine attacks. Indeed, medication adherence is a central component of behavioral migraine treatments. This multi-modal cognitive behavioral treatment approach to migraine described has demonstrated efficacy to reduce migraine symptoms and migraine-related disability when added to an acute treatment regimen; however, the most benefit for migraine symptoms occurs when a preventive behavioral treatment approach is combined with a preventive medication (Holroyd et al., 2010). This highlights the importance of working with the physician managing migraine to optimize the behavioral management and medication regimen to reduce migraine symptoms and disability.

Psychological Comorbidity

Migraine is highly comorbid with mood and anxiety disorders (Seng & Seng, 2016). People with migraine are two to four times more likely to have major depressive disorder, and three to five times more likely to have generalized anxiety or panic disorder, than the general population. More than one-third of people with bipolar disorder have migraine. Among people with migraine, the presence of psychological symptoms is associated with more severe migraine symptoms and migraine-related disability. Therefore, addressing depression and anxiety symptoms is a core component of psychological treatments for patients with migraine and any comorbid psychological disorders.

People with migraine and comorbid psychological symptoms are amenable to treatment. In fact, in one randomized clinical trial evaluating the addition of behavioral treatment, preventive medication, or their combination to acute migraine treatment, people with migraine and a comorbid depression and/or anxiety disorder diagnosis experienced larger reductions in migraine days and migraine-related disability than people without either psychological disorder (Seng & Holroyd, 2012). A recent trial demonstrated that a cognitive behavioral group treatment in people with comorbid depression and migraine or tension-type headache presenting in primary care successfully reduced both depression and headache symptoms, as well as improving quality of life, compared to routine primary care (Martin et al., 2015). Psychologists should therefore rigorously assess patients presenting with migraine for psychological disorders, and incorporate traditional interventions to reduce psychological symptoms into their overall treatment plan.

Building a Migraine Referral Network

Psychologists are an integral part of the migraine treatment team. Psychologists with training in cognitive behavioral techniques, health psychology, and pain psychology already have the building blocks for a successful headache psychology practice. Psychologists interested in treating people with migraine can also read more about behavioral interventions in a recently published book (Smitherman, Penzien, Rains, Nicholson, & Houle, 2015) in the “Advances in Psychotherapy” series (CE test available via the National Register), or seek additional training through workshops offered at national and regional psychology conferences. The Behavioral Issues Section of the American Headache Society is dedicated specifically to the science and practice of psychological and behavioral treatment of headache disorders.

Physicians who treat headache disorders are highly interested in developing referral networks of psychologists comfortable with treating migraine (Singer et al., 2015). The majority of people with migraine are treated in primary care settings. Psychologists should consider including migraine as one of the disorders for which they solicit referrals from their traditional primary care sources. Headache disorders, particularly migraine, comprise the majority of diagnoses treated in general neurology practices. Psychologists interested in treating migraine should develop a relationship with general neurology practices in their areas. Finally, headache centers treat people with a variety of headache disorders, including migraine. Patients presenting to headache centers are also more likely to have complicated headache symptom profiles, potential medication overuse, and comorbid psychological symptoms. Even headache centers that employ a psychologist often require additional outside psychological referral resources.