Headache is a frequent medical complaint, exceeded only by the common cold. The Nuprin Pain Report found that almost 3 out of 4 American adults experienced some form of headache within a given year, and that the complaint of headache resulted in nearly 127 million lost work days per year. In children, headache is a leading cause of school absences. The overwhelming majority of headache complaints are diagnosed as vascular or tension. The National Headache Foundation estimates over 10 million Americans are troubled by recurrent migraines, a form of vascular headache. And tension headache likely affects 3-4 times as many individuals. Both forms of headache are more prevalent in females. They do not appear to be related to social class, occupation, etc., and thus can occur in virtually anyone at anytime.

Mechanisms and Symptoms of Vascular and Tension Headache

A migraine or "sick headache" is experienced as a sudden onset, most often one-sided, intensely throbbing pain. Attacks are intermittent, lasting from a few hours to as long as a day or more. Nausea, vomiting, loss of appetite, fatigue, and sensitivity to sound and light frequently accompany the headache. A typical reaction to this type of vascular headache is to seek out a quiet, darkened area to lie down and 11 ride-out" the pain. A brief aura (physical warning sign) occurs in about 10- 15% of cases; these types of migraine are termed "classic." Auras are most often visual; seeing flashing lights or zigzag lines or experiencing a gap in the visual field. Migraines lacking strong, clear warning symptoms are labelled "common". Biochemical imbalances, fluctuations in cranial blood flow, and certain neurological events are thought to underlie migraine.
    Cluster headache is another type of vascular headache, so named because attacks come in bouts of frequent, but short duration headaches, then go away for extended periods of time. These headaches can be exceedingly painful and are often described as a stabbing pain ("like a hot poker is in my eye"). Cluster headache is rare and is the only type to be more common in males than females. Waking from sleep with a headache, blockage, and/or running of the nose, and redness and tearing of the eye on the same side as the head pain are hallmarks of cluster headache.
    Tension, or muscle contraction, headache is believed to result from excessive contraction of muscles in the shoulders, neck, and head. These contractures affect oxygen and nutrient intake to the muscles and impinge on pain sensitive structures, both of which contribute to the experience of pain. Recently it has been suggested that some cases of tension headache may actually be variants of vascular headache. The prototypical tension headache is experienced as a two-sided, gradual onset, dull, steady, vise-likeache, that waxes and wanes in intensity. It is not unusual for this type of headache to be a daily occurrence.
    Headaches can be an indication of a serious underlying organic problem, so it is always wise for individuals to have their symptoms evaluated by a medical specialist. This is especially important for headaches of a recent onset and for headaches where the nature or magnitude of symptoms have undergone recent change or progression in frequency and/or severity.

Cause of Vascular and Tension Headache

    Both forms of headache can be precipitated and/or exacerbated by a host of factors. Fluctuating hormone levels, diet (caffeine, chocolate, ripened cheese, etc.), alcohol, physical exertion, and birth control pills are just a few of the identified precipitants of migraine headache. Even medications routinely prescribed for headache can inadvertently intensify symptoms if taken at abusively highlevels, a condition termed "medication rebound headache."
    Physicians have long noted an association between stress and headaches. Stress can be associated with headache in three particular ways: 1) stress can directly trigger or set-off the biological events underlying headache, 2) stress can intensify an existing headache that the person might be experiencing, and 3) the prolonged presence of a headache problem itself can begin to exert a psychological toll (or stress) on the individual (the point at which the individual becomes "sick and tired of feeling sick and tired"). Depression and anxiety sometimes occur in people with headaches of longstanding, unremitting origin.
    A substantial number of individuals appear to treat their headaches effectively by rest, vacation, and over- the-counter medications. Cases where these selftreatments are ineffective are candidates for further specialized medical care and/or newly developed nonpharmacological treatment approaches, such as behavior therapy.

Behavior Therapy Treatment Approaches

    The behavior therapist will typically begin by assisting the patient in analyzing factors that might be precipitating, exacerbating, or maintaining headaches. The patient may be asked to make detailed recordings of these factors on a daily basis in a "headache diary," along with ratings of pain, frequency, severity, and duration. The latter information is helpful also in gauging progress during treatment. Three specific behavior therapy techniques have been developed for use with headache patients: biofeedback therapy, relaxation training, and stress coping training.

Biofeedback
    Biofeedback seeks to teach patients how to regulate the bodily processes that underlie headache. For example, in the treatment of tension headache, sensors are attached to the affected muscles (on the skin surface), the patient is provided ongoing information or "feedback" about activity in the monitored muscles, and with this information strives to lower the muscle activity to a more acceptable level as a way to alleviate pain. Biofeedback therapy for migraine involves teaching patients how to gain control of either their hand surface temperature (which provides a good index of nervous system arousal and blood flow) or their blood flow in the temple area (a common site of migraine).

Relaxation Skills
    The second form of behavior therapy involves training in general relaxation skills. A common relaxation technique has the patient engage in a systematic series of muscle tensing and releasing exercises, which help to produce an overall relaxed state. Biofeedback and relaxation have a similar goal; the former works with specific bodily response systems, while the latter targets the entire body.

Stress Coping
    Stress coping training, the remaining behavioral treatment, seeks to provide patients with a general set of problem-solving or coping skills that can be used to manage a wide range of situations associated with headache. This treatment uses various cognitive and behavioral treatment techniques to keep stress factors more manageable. For example, patients may be taught variously how to become less reactive emotionally, to interpret potentially upsetting situations more objectively, to manage time, interpersonal situations, and the like more effectively, and to react better to the psychological distress that can result from chronic headache itself. It is not uncommon for the behavior therapist to use all of these techniques in concert.
    Many patients seen by a behavior therapist will be receiving medication and other medical treatments from their physician. The behavior therapist typically maintains close contact with the physician to ensure that treatment efforts remain coordinated. Comprehensive reviews of research studies conducted over the past 17 years reveal all 3 types of treatment are similar in effectiveness and lead to meaningful improvement in approximately 40-60% of patients. Not all patients successfully treated become completely symptom-free. For some, treatment is judged successful when the patient copes more effectively with headache and the presence of headache no longer disrupts planned activities.

    The ASSOCIATION FOR ADVANCEMENT OF BEHAVIOR THERAPY is a professional, interdisciplinary organization which is concerned with enhancing the human condition through the scientific investigation and application of the principles of human behavior.
    For more information, please contact AABT at 15 West 36 Street, New York, NY 10018 (212) 279-7970.
    May, 1988