Behavioral Medicine Approaches to Migraine

Multiaxial Assessment

All workups for headache evaluate frequency, intensity, duration, and disability. From a behavioral perspective, Dr. Baskin recommended considering a few more factors—adherence to therapy, stress-related issues, comorbid psychiatric disorders, and factors that transform migraine from episodic to chronic.

“When you talk about adherence, one of the basics of this is readiness to change,” said Dr. Baskin. “Is the patient motivated for treatment? That doesn’t necessarily happen immediately.” For example, a patient who is motivated to have an abortive agent might not be motivated to pursue prevention, lose weight, exercise, or make lifestyle changes. “Over time, that might change,” Dr. Baskin noted. Patient motivation may evolve with a greater understanding of the goals of treatment.

“Has the patient adhered to past therapy regimens? If the answer is no, then the answer will most likely be no again,” Dr. Baskin said. If medication overuse was a problem, it may be again. Whenever possible, ask open-ended questions, such as “how do you decide when to take an acute medication?” Dr. Baskin advised.

Stress and Migraine

High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic. “Patients with depression show a greater effect of stress,” Dr. Baskin said. Similarly, victims of trauma or childhood maltreatment can have more disabling headaches that may be more likely to transform into daily headaches. “Many patients do not have the coping skills necessary to manage stress or recurrent headache,” Dr. Baskin said. One of the goals of behavioral therapy for migraine is to increase patients’ self-efficacy and give them the tools and the confidence to manage headaches and stressors.

Psychiatric Comorbidity

Psychiatric comorbidity may complicate differential diagnosis, and nonadherence to medication is greater in people with mood disorders and anxiety disorders. These patients may show a reduced response to pharmacologic and behavioral treatments for headache. Psychiatric comorbidities also can contribute to migraine chronification. “However, if you add a small behavioral component to your headache program, patients with psychiatric comorbidities seem to respond relatively well,” Dr. Baskin said.

Migraineurs have a two- to threefold greater prevalence of depression. There is a bidirectional relationship between migraine and depression in population studies. The relationship between migraine and depression is greater in clinic populations, in chronic migraine, and in medication overuse headache.

There is a significant relationship between migraine and anxiety disorders. Anxiety disorders entail a sense of danger, fear, or worry. “All patients with anxiety disorder have physical symptoms, and they often show avoidance behaviors,” said Dr. Baskin. For example, in generalized anxiety disorder, the object of avoidance is probably the fear of uncertainty. People worry excessively, thinking they are avoiding uncertainty. “Avoidance learning is huge in anxiety,” said Dr. Baskin. People fear unexpected events and perceive things as more unmanageable, dangerous, or threatening than they objectively are. “We see that frequently in migraineurs with anxiety disorders,” he said. Dr. Baskin noted that anxious patients tend to be sensitive to medication side effects and somatic sensations in general.

Patients with headache and anxiety often develop strong fear reactions. They identify a warning signal for headache, real or imagined, and may treat their fear, which they perceive as a headache prodrome, with a medication. “There is a preemptive strike with medicine treating a sensation that may or may not develop into headache,” Dr. Baskin said. That medication reduces their emotional distress and prevents the migraine, a powerful avoidance learning paradigm. That cycle can be a major part of medication overuse headache.

Anxiety disorders are much more prevalent than depression in migraineurs. They are associated with greater long-term persistence of headache, greater headache-related disability, and reduced satisfaction with acute therapy. “Across all emotional disorders, anxiety is the driver of distress,” Dr. Baskin said. “When you add anxiety to any disorder, it becomes much more problematic.”

The concept of interoceptive awareness—an individual’s sensitivity to bodily signals—is important in people with panic disorder. Like people with panic disorder, some migraineurs often have high interoceptive awareness. Anxiety sensitivity—fear that benign physical sensations will have harmful or catastrophic consequences—also may be a factor in panic disorder, as well as migraine. As in panic disorder, highly anxious migraineurs may develop hypervigilance to somatic sensations and conditioned fear to these internal sensations.

Dr. Baskin recommends screening patients for psychiatric comorbidity. He recommends two questions from the Patient Health Questionnaire-9 screener—“Do you have little interest or pleasure in doing things?” and “Are you feeling down, depressed, or hopeless?”—and two additional anxiety questions—“Are you feeling anxious, nervous, or on edge?” and “Are you unable to stop or control worrying?” “With just those four questions, you can capture a good number of people with anxiety or mood issues,” Dr. Baskin said.