Psychological Treatments of Tension-Type Headaches

Kenneth A. Holroyd

Paul R. Martin

Justin M. Nash

In this chapter, we address the following questions: (a) What is psychological treatment? (b) How effective are psychological treatments? (c) How long do treatment improvements last? (d) Who can benefit from psychological treatments? (d) Can we increase the cost-effectiveness and availability of psychological treatments? (e) How do psychological treatments improve tension-type headache?, and (f) How can psychological and drug therapies be combined?

WHAT IS PSYCHOLOGICAL TREATMENT?

A number of psychological treatments for tension-type headache have been described including EMG biofeedback training, relaxation training, cognitive-behavioral therapy, feedback of temporal artery diameter, digital temperature biofeedback training, neurofeedback, hypnotic analgesia, and transcendental meditation. The research evidence is very limited, however, on the last five approaches, so only the first three treatments are discussed.

Relaxation Training

Progressive relaxation training (PRT) is the most frequently used form of relaxation training. The goal of PRT is to help the learner recognize and control tension as it arises in the course of daily activities. The most commonly used training procedure is an abbreviated version of procedures originally developed by Edmund Jacobson in the 1930s (6). During PRT training, the learner sequentially tenses and then releases specific groups of muscles throughout the body. PRT typically begins with 16 muscle groups, and then combines muscle groups to form 7 groups, finally combining muscle groups to form 4 muscle groups. Later stages of training involve relaxation by recall (eliminating the tense stage from tense-release exercises), cue-controlled relaxation (association of relaxation with a cue word such as calm), and differential relaxation (maintaining relaxation in muscles not needed for current activities). Practice of relaxation exercises at home is encouraged and audiotapes are often provided to guide this practice. As the trainee learns to recognize signs of tension and rapidly relax, they are encouraged to use their relaxation skills throughout the day to prevent and abort tension-type headaches. Table 81-1 describes a typical eclectic combination of relaxation techniques.

EMG Biofeedback Training

EMG biofeedback provides the trainee with continuous feedback about muscle activity, with the goal of helping the trainee learn to recognize and control muscle tension (46). Feedback is usually provided from the frontalis area (active electrodes placed 1 inch above the center of each eye), but may also be provided from the temporalis, trapezius, and, other muscle areas (Fig. 81-1). Training sessions typically include an adaptation phase, baseline phase, training phase where feedback is provided, and a self-control phase where the trainee practices controlling muscle tension without the aid of feedback. As biofeedback trainees learn to recognize and control muscle activity, they are encouraged to use this skill throughout the day to prevent and abort tension-type headaches.

Cognitive-Behavioral Therapy

Cognitive therapy teaches patients to identify and challenge thoughts and beliefs that generate stress and aggravate headaches (22). Thoughts are monitored in stressful situations and when headaches occur, with an eye toward
identifying stress-generating thoughts. These thoughts are then examined and challenged, and alternative adaptive coping self-instructions are considered and tried out. Where stress-generating thoughts reflect dysfunctional beliefs or assumptions, beliefs also are challenged, and the pros and cons of alternate adaptive beliefs considered. A variety of exercises may be used to challenge thoughts and beliefs, including reversing positions (experimenting with adoption of another persons view of the situation), reframing (actively generating other possible views
of a situation), and reality testing (devising a behavioral experiment to test the validity of a particular belief). Table 81-1 describes common techniques employed in cognitive therapy.

TABLE 81-1 Relaxation, Cognitive, and Pain Management Techniques

Relaxation
Progressive muscle relaxation	Systematic use of muscle tension and release exercises to achieve relaxation.
Muscle stretching	Gentle stretching of neck and shoulder muscles to lengthen and relax sore and tight muscles
Imagery	Creating a relaxing mental image and focusing on the sensory experiences associated with the image (e.g., tranquil beach scene)
Relaxation by recall	Inducing relaxation without first tensing muscle groups by recalling sensations associated with muscle relaxation
Cue-controlled relaxation	Use of a cue or signal that has been repeatedly paired with relaxation to induce relaxation
Abdominal breathing	Slow, paced breathing from the diaphragm
Autogenic phrases	Use of repeated phrases to elicit sensations of relaxation (e.g., “My arm feels warm, heavy and relaxed”)
Cognitive-Behavioral Therapy
Challenging stress-generating thoughts	Use of self-talk to challenge stress-generating thoughts and develop adaptive coping statements (e.g., “I will focus just on the task in front of me instead of worrying I will not be able to complete the project until next week”)
Challenging stress-generating beliefs	Identifying and evaluating core beliefs that underlie stress-generating thoughts and developing an alternative perspective (e.g., “Instead of automatically assuming my boss is unhappy with me when I have no information, I will challenge my tendency to think in this habitual way. Instead I will evaluate the evidence for my fear.”)
Pain Management
Brief relaxation	Using brief relaxation techniques to keep the emotional distress and physiologic arousal that accompany pain from further aggravating pain in a vicious cycle
Cognitive restructuring	Challenging pain-related worries (e.g., “Just because the pain has started I don’t have to jump to the conclusion my whole weekend is ruined”)
Attention diversion: imagery	Mentally shifting attention away from the pain to involvement in a vivid mental image (e.g., favorite vacation spot)
Attention diversion: concentration	Mentally shifting attention away from the pain to a pleasant or neutral cognitive task (e.g., recalling lyrics of a song)
Pain transformation	Use of imagery to alter or transform sensory qualities of pain (e.g. pounding pressure is imagined to be a drumbeat that becomes slower and softer over time)

FIGURE 81-1. Schematic of EMG biofeedback training. Frontal area and trapezius muscles are being monitored with ground on the ear lobe.

Detailed descriptions of psychological treatment techniques as well as discussions of clinical issues that arise in administering psychological treatment and exemplary case studies can be found in numerous sources (4,5,8,25,26,32,33,46).

HOW EFFECTIVE ARE PSYCHOLOGICAL TREATMENTS?

Available studies have been conducted primarily in headache clinics or in specialized university or medical school settings, and generally have been small, averaging about 20 patients per treatment group (12,35). Information about the results that can be expected when relaxation/biofeedback therapies are integrated into the primary care or a general neurology setting, or when these therapies are administered conjointly with drug therapies, thus remains limited.

Meta-analytic and narrative reviews have concluded that EMG biofeedback training, relaxation training, and cognitive-behavioral therapy effectively reduce tension-type headaches (12,29,35). Table 81-2 summarizes results from 89 active treatment groups and 37 control groups where daily headache recordings were used to assess treatment outcome (daily headache recordings yield relatively conservative estimates of treatment outcome). When results are averaged across studies, EMG biofeedback training, either when administered alone or with relaxation training, and cognitive-behavioral therapy are each found to yield at least a 50% reduction in tension headache activity. Improvements reported with these three treatments as well as with relaxation training alone also are significantly larger than improvements reported with placebo control treatments, or observed in untreated patients; however, these four treatments did not differ significantly among themselves in effectiveness.

Cognitive-behavioral therapy may be particularly useful where psychological problems or environmental demands (e.g., chronic work stress, affective distress, other adjustment problems) not addressed by relaxation or biofeedback therapies aggravate headaches or prevent patients from effectively using headache management skills. Thus, in one study, patients exhibiting high levels of daily life stress (as assessed by the Hassles Scale [14]) were unlikely to improve with relaxation training alone, but were likely to improve when cognitive-behavioral therapy was added to relaxation training (49).

TABLE 81-2 Mean Percentage Improvement by Type of Treatment

	*EMG Biofeedback Training*	*Relaxation Training*	*Biofeedback Training + Relaxation Training*	*Cognitive—Behavioral Therapy*	*Placebo*	*Headache-Recording Control*
Mean (%) improvement	48	36	59	53	16	1
Treatment groups (n)	28	37	9	15	21	16
Improvement range (%)	−18 to 96	4 to 99	37 to 89	27 to 76	−70 to 74	−33 to 26
Source: Borgaards and ter Kuile (12).

HOW LONG DO TREATMENT IMPROVEMENTS LAST?

Improvements achieved with psychological treatments have generally been maintained, at least for the 3- to 9-month follow-up periods that have most frequently been assessed. For example, in 22 patient samples included in one meta-analytic review, improvements reported at such short-term follow-up evaluation (54% reduction in headache activity) were larger than improvements (45% reduction) reported at immediate posttreatment evaluation (29).

Positive, but much less definitive, statements can be made about the long-term (greater than 1 year) maintenance of improvements. In five of six studies that employed daily headache recordings, reductions in tension headache activity of 50% or greater were still observed 1 to 3 years following relaxation, EMG biofeedback, or cognitive-behavioral therapy, and in one study, improvements of this magnitude were still observed 5 years following treatment (7). However, a significant proportion of patients are typically lost to follow-up in these studies, and patients who do complete the follow-up evaluation may have received other treatment during the follow-up period, so these findings must be interpreted cautiously. Booster sessions have not been found to enhance the maintenance of improvements, possibly because good maintenance has frequently been found without booster sessions (2,10). It is possible, however, that patients at high risk for relapse would benefit from booster sessions. Patients discussed in the next section might thus be reasonable candidates for booster sessions.

WHO CAN BENEFIT FROM PSYCHOLOGICAL TREATMENT?

Common clinical problems that arise in administering psychological treatments are discussed herein. For the most part, the patients who require special attention in psychological treatment also require special attention when administering drug therapy.

Analgesic Use

Excessive analgesic use limits the benefits likely to be obtained from either psychological treatment or from prophylactic pharmacotherapy. In one retrospective review of patient records (37), less than one third of “high medication users” showed a 50% or greater reduction in headache activity following psychological treatment, whereas more than half of low medication users showed this level of improvement. High medication users in this study were defined by a score of 40 or greater on a weighted medication index, a score obtained by the consumption of at least six aspirin or three aspirin plus butalbital and caffeine (Fiorinal) pills per day, or equivalent medication.

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