Behavioral Medicine Approaches to Migraine
Behavioral Therapy
“Our behavioral medicine program is time-limited and goal-oriented,” said Dr. Baskin. “We try to get people to develop self-efficacy and personal responsibility. We monitor and maximize adherence to medications and help patients to regulate their routine activities, including going to bed, getting up, and exercising on a consistent schedule. We offer biofeedback for self-regulation, relaxation and coping skills training utilizing a cognitive behavioral model, and we treat psychiatric issues,” said Dr. Baskin. Many of those things can be done by clinicians who are not behavioral clinicians, he said. “You do not necessarily have to refer all these people. Schedule frequent revisits for complicated or difficult patients. Do not overwhelm patients with too much information. Simplify jargon, provide written instructions, and make sure the patient understands the plan.”
An important component of behavioral treatment is teaching relaxation exercises, which can reduce muscle tension and autonomic arousal. There are many types of relaxation strategies. Dr. Baskin recommended breathing pacer apps, which are designed to encourage slower abdominal breathing. The goal is to gradually reduce the breathing rate to six breaths per minute for five- to 10-minute practice sessions. “If you can teach people diaphragmatic breathing—it takes about 30 seconds to begin the discussion—it is helpful.” Dr. Baskin recommended having patients do it three to five times per day for a few minutes at a time.
“We deliver relaxation training alone, sometimes with biofeedback, and teach it as a self-regulation coping skill. We try to get people to develop an internal locus of control so they can manage some of their own physiology, relax muscles, and learn a nonspecific low-arousal response and use it as a coping skill to apply in different situations,” Dr. Baskin said.
Cognitive behavioral therapy is another tool. It gives people an opportunity to modify distress-related thoughts and to examine their personal danger cognitions, their sense of threat, and the negative predictions that they may have. Dr. Baskin uses cognitive behavioral therapy to help patients develop an action plan based on their prescribed strategy to treat an acute migraine attack as well as manage concomitant emotional reactivity and maintain functionality in the presence of a significant headache disorder.
Trigger Management
Historically, migraineurs have avoided headache triggers. The down side to that strategy is that they can unnecessarily restrict themselves. Studies suggest that avoiding triggers may lead to sensitization to those triggers. Gradual exposure coping models are being developed. “Cope, do not avoid,” Dr. Baskin said.
Biofeedback
Relaxation training, EMG biofeedback, thermal biofeedback, and cognitive behavioral therapy show grade A but modest efficacy. There is recent evidence that combining behavioral therapy with preventive pharmacologic treatment improves outcomes. The behavioral section of the American Headache Society will soon be reviewing the most recent evidence on behavioral interventions in migraine.
Sleep Hygiene
Three main messages regarding sleep are to adopt a routine, consistent bedtime and wake up time, avoid all non–sleep-related activities at bedtime, and employ relaxation strategies to reduce sleep onset latency. In addition, patients should not eat or drink a lot of fluid too close to bedtime, not exercise in the evening, and avoid napping. A patient should be advised that if he or she cannot sleep, the best solution is to get out of bed, go to another room in the house, engage in a relaxing activity, and go back to bed when he or she gets tired. With these strategies, clinicians have converted chronic migraine to episodic migraine for a significant number of patients.
Combination Treatment of Migraine and Psychiatric Disorder
Many doctors support the idea that one drug should treat migraine and associated conditions whenever possible. The idea is to use one agent to treat migraine and associated conditions (“two-fer”) This strategy is simpler and may entail lower cost, fewer adverse events, and fewer potential drug interactions. “It makes sense on one level, however, there’s a risk of treating only one condition optimally or treating none of them optimally,” Dr. Baskin said. “It is important to treat both disorders the way you think they should be treated. Sometimes two drugs are better than one. You want to treat both conditions effectively.”
When treating anxiety disorders with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs), prescribers should know that people with anxiety are exceptionally sensitive to side effects. Also, anxiety disorders often require higher doses than treating depression. “You should start dosing incredibly low and titrate slowly,” Dr. Baskin said.
—Glenn S. Williams
