Introduction

Self-management of chronic disease refers to active involvement in monitoring and managing one’s “symptoms, treatments, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition…and to effect the cognitive, behavioural, and emotional responses necessary to maintain a satisfactory quality of life” ([1], pp. 178). As it pertains to chronic headache disorders, effective self-management requires that individuals (a) self-monitor headache information (e.g., warning signs, triggers, and medication use and response), (b) employ specific behavioral headache management and general problem-solving skills, and (c) possess appropriate motivation and self-efficacy to utilize these skills for managing headache in daily life.

Inherent to effective chronic disease self-management, patients must exercise primary responsibility for managing their own conditions but must also collaborate with their health care providers to (a) effectively and routinely engage in healthful behaviors to prevent or limit worsening of the condition and (b) understand and employ appropriate medication and behavioral strategies to treat symptoms when they occur [2]. Thus, responsibility for facilitating self-management belongs to health care providers and requires that health care providers practice principles of patient-centered care [3] to develop a comprehensive treatment plan that addresses the “whole patient” through mutually established goals and strategies [4].

Myriad self-management interventions have demonstrated effectiveness for improving quality of life and reducing symptoms, disability, and medical costs [5–7] for various chronic medical conditions [8, 9], including cardiovascular disease and arthritis [8], asthma and chronic pulmonary diseases [10, 11], diabetes [12], obesity [13], and low back pain [14, 15]. Though the treatment of chronic headache disorders is well suited for such an approach, applications of the self-management model have yet to be widely employed [16].

Behavioral Interventions

Behavioral interventions for the treatment of headache are viable among individuals who have one or more of the following characteristics: (a) preference for nonpharmacologic interventions; (b) poor tolerance of pharmacologic treatment; (c) medical contraindications for pharmacologic treatments; (d) inadequate response to pharmacologic treatment; (e) pregnancy, planned pregnancy, or nursing; (f) history of excessive use of analgesic or other acute medications; and (g) life stress, deficient coping skills, or a comorbid psychological disorder that aggravates headache problems or disability [17–19]. Long-term goals of behavioral headache therapies include reductions in headache frequency, severity, and associated disability and affective distress; reduced reliance on pharmacotherapies that are poorly tolerated, unwanted, or overused; and improved self-efficacy for personal control of headache.

The primary components of nearly all well-established behavioral interventions for headache include various combinations of (a) relaxation training, (b) biofeedback training, and (c) stress management training (i.e., “cognitive behavioral therapy”). These behavioral interventions are most effectively applied within the context of a self-management model, as each intervention strategy equips patients with unique skills for managing headache and related disability and for preventing future headache episodes. Initially educating patients about the nature of and rationale for these interventions is advantageous for allaying patient fears and misconceptions, as is differentiating the role of the mental health provider from the role of the physician. For example, patients should be advised that behavioral therapies typically supplement, not replace, medication treatments and that combination therapy often produces better outcomes than either treatment modality alone. Drawing parallels between headache self-management interventions and well-established self-management interventions for other chronic diseases (e.g., diabetes, asthma) can prove beneficial.

Relaxation Training

Relaxation skills purportedly allow individuals to reduce counterproductive physical and mental arousal and can enable headache sufferers to exert control over specific headache-related physiological responses [20]. Through the process of formal relaxation training exercises, patients receive instruction in practicing a graduated hierarchy of relaxation techniques (progressive muscle relaxation, diaphragmatic breathing, relaxation inducing imagery, meditative exercises) initially for 20–30 min twice daily. As they are able to master the relaxation training exercises, increasingly brief and efficient relaxation techniques are introduced (e.g., cue-controlled relaxation, self-control relaxation), and they are encouraged to practice their newly acquired techniques of relaxation induction throughout the day.

Biofeedback Training

Biofeedback training uses purpose-built monitoring devices (usually electronic) that help patients learn to control headache-related physical responses. Biofeedback devices measure and then “feedback” information about the physical response to the patient. Electromyographic (EMG) biofeedback—feedback of electrical activity from muscles of the scalp, neck, or sometimes the upper body—can help patients learn to recognize and reduce muscular tension. Thermal or handwarming biofeedback—feedback of skin temperature from a finger—can help patients learn to reduce central nervous system arousal by increasing body temperature. Although thermal and EMG biofeedback are the most commonly used biofeedback modalities, electroencephalographic (“neurofeedback”) biofeedback with the goal of teaching self-regulation of cortical excitability has received recent attention [21].

Stress Management Training

Stress management training directly targets the behavioral, cognitive, and affective components that precipitate, exacerbate, and perpetuate headache. Because stress is a frequent precipitant of migraine headache attacks, stress management training offers a face-valid introduction to behavioral headache interventions. Although many use the terms “stress management training” and “cognitive behavioral therapy” interchangeably, we prefer the “stress management” terminology because it typically is perceived as less stigmatizing to patients (particularly those not psychologically minded) and because the techniques that formally comprise cognitive therapies (e.g., cognitive restructuring) often are not primary in stress management interventions for headache. The core components of stress management training typically include (a) psychoeducation about the intervention, (b) teaching the patient to self-monitor and analyze stressful situations, (c) implementing problem-solving skills to adaptively manage stressors, and (d) headache trigger management (i.e., learning to identify and better manage headache triggers).

Behavioral Intervention Formats

Behavioral interventions are suitable to be administered with individuals or groups, in clinics, and in limited or no face-to-face contact settings with a behavioral clinician via telephone, the Internet, or mass media.

Clinic-Based Interventions

In mental health settings, behavioral headache interventions typically are administered over the course of 6–12 weekly sessions. Sessions are typically 45 to 60 min in duration for individuals and 60 to 120 min in duration for groups of patients. Whereas clinic-based intervention formats allow for more health care provider time and attention, and greater observation of the patient than limited therapist contact formats (see below), they are more costly to administer with respect to clinician time and patient inconvenience (e.g., scheduled appointment times, travel) and expense. Detailed descriptions of clinic-based behavioral treatments are available in Smitherman and colleagues [17].

Limited Contact Interventions

The limited therapist contact interventions principally employ the same therapeutic components as the clinic-based behavioral treatments referenced above but typically involve as few as one or two monthly treatment sessions [22, 23]. Clinic sessions are used to introduce headache management skills and address problems encountered in acquiring or using these skills. Patient manuals and audio recordings are utilized to guide patients in acquiring and refining headache self-management skills, which can be practiced at home and with clinician assistance via various forms of periodic communication (e.g., telephone, the Internet, text, e-mail) to assess adherence, address obstacles to skills acquisition and implementation, and document progress.

Nonprofessional-Administered Treatment

The self-management interventions in other arenas have made excellent use of treatment groups led by trained nonprofessionals who suffer from the chronic disorder being targeted (arthritis, asthma, diabetes, and chronic back pain) under professional supervision. Studies have shown promise for lay-led migraine self-management groups in yielding at least modest benefit with respect to improved headache outcomes, reduced health care utilization, and enhanced patient self-efficacy [13, 24–26].

No Professional Contact or “Strictly Self-Help” Interventions

If patients were able to implement self-management interventions without face-to-face professional assistance (i.e., strictly self-help treatment), behavioral headache interventions could be made ubiquitous. Although many headache sufferers are capable of acquiring headache self-management skills on their own and with the benefit of suitable instructional materials, few studies to date have evaluated self-help interventions for headache. The few studies published to date, perhaps quite predictably, have suffered from high attrition rates. For example, one trial reported an admirable 62 % reduction in headache at post-treatment (vs. only 14 % for “information control”), but the attrition rate exceeded 60 % [27]. Despite the high dropout rate, this report nevertheless indicates that self-help treatments can be beneficial for suitably motivated patients.

Technology-Assisted Self-Management Interventions

With the recent revolution in telecommunications, various forms of technology (e.g., mobile smart phones, the Internet, interactive voice response, telephone, virtual reality) increasingly are being creatively employed to both accumulate and deliver health-related information and interventions. This most assuredly includes delivery of self-management interventions for a variety of chronic conditions including chronic pain [28]. Perhaps best demonstrated is the potential for Internet-based applications for migraineurs, with publications to date reporting promise for web-based treatment applications targeting adults [29–32] and children/adolescents alike [33–35].

Efficacy of Behavioral Treatments for Migraine

Since the earliest empirical examination of a behavioral intervention for headache in 1969 [36, 37], a considerable evidence base addressing behavioral headache interventions has emerged (now over 300 studies in print), and this literature has exerted a substantive influence on contemporary head pain management [22]. This impressively large literature uniformly has reported positive outcomes (i.e., behavioral treatments are more effective than control conditions; behavioral treatments are similarly efficacious with preventive pharmacotherapy), leading numerous professional practice organizations to recommend use of behavioral headache treatments as front-line interventions for migraine. A series of systematic reviews of this literature has been prepared employing varying study inclusion/exclusion criteria. The earliest of these reviews opted to include the evidence from all available treatment studies, regardless of experimental design or publication status. More recently, meta-analytic reviews have selectively summarized the best designed and reported studies (e.g., randomized and controlled trials, head-to-head comparator trials).

Perhaps the most ambitious systematic review was published by Goslin and colleagues [38]. With backing from the Agency for Healthcare Research and Quality (AHRQ), they opted to employ conservative inclusion criteria with respect to study design and reporting and thus examined the findings of the controlled trials adjudged to be the most reliable and valid. Their literature search revealed 355 articles describing behavioral and physical treatments for migraine in adults; of those, 70 were controlled trials, 39 of which met their stringent design and data requirements. Outcome data were calculated using two metrics: summary effect size estimates (d scores) and mean headache improvement (% change from pre- to post-treatment). The behavioral treatments yielded 35 to 50 % reductions in migraine vs. 5 and 10 % reductions for no-treatment and for other control conditions, respectively (Fig. 1). Analyses of effect sizes revealed that relaxation training, thermal biofeedback combined with relaxation, electromyographic biofeedback, and cognitive behavioral therapy all were statistically more effective than wait list control.

Fig. 1
figure 1

Percent headache improvement scores for behavioral and pharmacological treatments for migraine from four meta-analyses (Temperature BF temperature biofeedback training, EMG BF electromyographic biofeedback training, RLX relaxation training) [23, 38, 44, 45]

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While examining only studies of biofeedback training, the findings of the most recent systematic review of behavioral migraine treatment were highly consistent with the Goslin et al. [38] analysis [39]. This biofeedback review identified 86 studies, of which 55 met criteria for inclusion in their meta-analysis. Biofeedback therapies for migraine yielding an effect size of d = 0.58 (95 % CI = 0.52, 0.64) were significantly more effective than control conditions, and observed treatment gains proved stable over follow-up periods averaging 17 months post-treatment.

Drawing upon the evidence from the AHRQ meta-analysis [38], the US Headache Consortium (a multidisciplinary assemblage of seven professional practice organizations: American Academy of Family Physicians, American Academy of Neurology, American Headache Society, American College of Emergency Physicians, American College of Physicians, American Osteopathic Association, and the National Headache Foundation; [40]) made the following recommendations pertaining to behavioral interventions for migraine: (1) relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive behavioral therapy are treatment options for prevention of migraine (grade A evidence) and (2) behavioral therapy may be combined with preventive drug therapy to achieve added clinical improvement for migraine (grade B evidence) [19]. Today, the evidence for the latter recommendation undoubtedly would be adjudged grade A given the publication of additional and compelling controlled clinical trials in support of the recommendation [41••, 42, 43••].

Behavioral vs. Pharmacologic Interventions

The comparative efficacy of drug and behavioral interventions for primary headache disorders seldom has been assessed in head-to-head studies; only a few head-to-head landmark studies have been published [41••, 42, 43••, 44]. However, meta-analytic comparisons have revealed similar and clinically meaningful levels of improvement in migraine using propranolol (an FDA-approved beta-blocker for migraine prevention; 32 trials) or combined relaxation and biofeedback training (35 trials) [45, 46]. In contrast, placebo medication (administered as per a preventive medication schedule) yielded on average only a 12 % improvement (Fig. 1). While meta-analytic comparisons of behavioral interventions with the other FDA-approved migraine medications are not available (owing in part to the limited number of controlled trials examining these medications), there is little to suggest findings would differ. Likewise, the few published trials offering direct comparisons of preventive medications with behavioral interventions have produced no indication that there are significant differences in headache outcomes. Thus, while the two treatment modalities offer distinct advantages and disadvantages within particular patient subgroups, the best of the preventive pharmacologic and behavioral therapies are similarly viable interventions for unselected migraine patients.

Notwithstanding their similar viability, and as concluded by the US Headache Consortium, sufficient evidence indicates that combining drug and behavioral interventions yields enhanced outcomes relative to either intervention strategy employed singularly. This point was well illustrated in two recent, large-scale, and authoritative clinical trials [33, 37]. In addition to receiving optimized acute migraine medications, adult migraineurs in the first study were assigned to receive (a) a beta-blocker (propranolol or nadolol), (b) placebo medication, (c) cognitive behavioral therapy (CBT) plus beta-blocker, or (d) CBT plus placebo. The CBT was comprised of three to four clinic visits focused on progressive muscle relaxation training and stress management or thermal biofeedback, with at-home skill practice and periodic phone follow-ups. Only those receiving CBT plus beta-blocker demonstrated significant reductions in headache frequency compared to acute treatment plus placebo. Approximately 75 % of the CBT plus beta-blocker group showed clinically significant improvements (i.e., ≥50 % reductions in migraine frequency) in contrast with 34 to 40 % of patients clinically improved in the other three treatment groups. In the second trial, behavioral therapy plus amitriptyline was compared to amitriptyline plus headache education (control) among a large sample of youth with chronic migraine [43••]. Two thirds of those in the behavioral therapy plus medication group achieved a clinically significant reduction in headache (which rose to 88 % at 12 months follow-up), compared to approximately one third of those in the medication plus behavioral control condition. Additional benefits thus accrue when efficacious behavioral and pharmacological migraine therapies are combined, likely owing to differing but complementary mechanisms of action.

Conclusions

Efficacy of behavioral headache interventions has been unequivocally demonstrated, with effect sizes comparable to pharmacological therapy, but the legacy of self-management for headache has yet to be fully realized. Since the first treatment study in 1969, the literature has amassed over 300 publications. Behavioral interventions have earned a grade A evidence rating in meta-analyses and are commonly recommended alongside the established medications for headache prophylaxis. Behavioral interventions are essentially free of adverse events and improvements are durable. But behavioral headache interventions continue to face significant challenges: methodological criticisms of research remain; publication of behavioral trials has declined since the 1970s and 1980s, when psychophysiological studies and controlled trials peaked; and dissemination of behavioral treatments into everyday clinical practice has been limited. In part, these challenges stem from the inability to conduct a truly double-blind trial of behavioral interventions and limited availability of behaviorally trained headache clinicians [47, 48].

The science of behavioral headache treatments would be enhanced by studies of replication of seminal work using revised diagnoses differentiating migraine, tension-type, and other headache disorders; improved research methodologies with expanded sample sizes, improved control groups, and head-to-head comparisons with efficacious preventive medications; and improved statistical analyses [22]. Studies are needed to elucidate the exact mechanisms of behavioral treatments [49], which are likely multifactorial. Likewise, clinical practice would benefit from the development of an empirically validated treatment algorithm that matches treatment to unique patient characteristics, paralleling or preferably integrated with the practice algorithms for pharmacological treatment.

Despite empirical support, behavioral interventions are not widely available to the average headache patient. Multidisciplinary headache practice is the exception rather than the rule and generally reserved for the most refractory cases or those with significant psychiatric comorbidity. Integration of behavioral interventions into first- or second-line headache care is virtually nonexistent and requires neurology and primary care providers to forge relationships with a relatively small supply of health or behavioral medicine psychologists trained in headache. Thus, the large majority of headache patients have little to no access to behavioral treatments, despite their strong efficacy. Technological developments offer potentially unprecedented access, if treatment integrity can be retained. Future research is needed to establish efficacy of online or mass media interventions and develop treatment algorithms to ensure appropriate delivery of care. With continued research and technological advances, the field of behavioral medicine will be better positioned to meet the great need for safe and effective interventions for migraine, the third most common medical condition to burden public health on a global scale [50].