Table 1.
Description of activities in each therapy session
| First session |
| Therapeutic agreement and psychoeducation |
| 1. Forming a therapeutic agreement between patients and the therapist regarding number of therapy sessions and their durations, the process of treatment, and confidentiality issues |
| 2. Educating patients about the nature and causes of headaches and its comorbid psychological disorders and discussing definition of anxiety |
| 3. Explaining the importance of completing homework at home, and providing instructions on homework, |
| 4. Giving homework to patients on self-monitoring (recording dates of experiencing headaches, duration of the pain, and its severity based on a scale from 0 to 10; rating the average daily anxiety level on a scale of 0 to 100) |
| 5. Asking patients to provide a list of situations that are associated with distressing anxiety for them |
| 6. Briefly explaining the content of the next session |
| Second session |
| Educating relaxation training and hierarchy of behavioral avoidance |
| 1. Educating relaxation techniques and preparation of hierarchy of behavioral avoidance for the better management of headache and anxiety responses |
| 2. Evaluating patients’ homework on self-monitoring and analyzing headache triggers |
| 3. Explaining the components of anxiety to patients |
| 4. Giving homework to patients on relaxation exercises |
| 5. Giving homework to patients on self-monitoring |
| 6. Briefly explaining the content of the next session |
| Third session |
| Automatic negative thoughts and guided imagery |
| 1. Evaluating patients’ problems in practicing relaxation techniques and preparing a hierarchy of behavioral problems as an important part of the treatment |
| 2. Discussing the importance of thoughts and educating how to identify automatic negative thoughts |
| 3. Giving homework to patients on recognizing and recording automatic negative thoughts |
| 4. Evaluating headache and anxiety daily diary recorded by the patient |
| 5. Delivering a CD containing audio on guided imaginary to patients to practice with at home |
| 6. Briefly explaining the content of the next session |
| Fourth session |
| Cognitive restructuring |
| 1. Ensuring that the patients have performed their self-monitoring homework and relaxation exercises |
| 2. Assessing automatic thoughts identified by patients during the past week |
| 3. Educating patients on how to challenge automatic thoughts |
| 4. Educating patients on cognitive errors and helping them to identify such errors |
| 5. Addressing patients’ ambiguities |
| 6. Briefly explaining the content of the next session |
|
Fifth session Problem solving skills and distraction technique |
| 1. Evaluating patients’ improvements in performing homework |
| 2. Educating problem solving skill and using role-playing techniques |
| 3. Educating distraction technique to reduce overthinking |
| 4. Giving homework on problem solving and distraction skills |
| 5. Briefly explaining the content of the next session |
| Sixth session |
| Exposure and cognitive restructuring |
| 1. Evaluating problem solving homework, assessing learned skills and the way patients apply them in their daily lives |
| 2. Educating self-directed exposure to patients and giving them homework on this skill |
| 3. Educating advanced cognitive reconstruction steps and encouraging patients to apply them in real life situations |
| 4. Extensive focusing on daily general stress level instead of targeting a special problem |
| 5. Summarizing the session and addressing patients’ ambiguities |
| 6. Briefly explaining the content of the next session |
| Seventh, Eighth, and Ninth session |
| Advanced cognitive restructuring, stress management, assertiveness skills training, preparation for therapy termination |
| 1. Evaluating self-monitoring homework, exposure, and cognitive reconstruction of patients to ensure their proper learning and applying them by patients in their lives |
| 2. guiding patients in cognitive reconstruction processes |
| 3. Educating stress management, assertiveness skills, and the ability to say “No” |
| 4. Advising patients to continue cognitive reconstruction homework, stress management techniques, and assertiveness skills in appropriate situations |
| 5. preparing patients for the last therapy session |
| Tenth session |
| Relapse prevention and therapy termination |
| 1. Evaluating patients’ performances in stress management and assertiveness skills |
| 2. Encouraging patients to continue doing homework and rewarding themselves |
| 3. Educating patients to administer the learned therapeutic techniques in case of disease recurrence |
| 4.Summarizing previous sessions and getting feedback from patients on different therapy sessions and effectiveness of the learned techniques |
| 5. Discussing with patients about the new perspectives they need to learn about themselves and their problems |
| 6. Congratulating patients on completing therapy sessions and acknowledging their participation in the program |