Behavioral Self-Management and Headache-Related Distress

Source: Hoodin F, et al. Behavioral self-management in an inpatient headache treatment unit: Increasing adherence and relationship to changes in affective distress. Headache 2000;40:377-383.

Context: In outpatient settings, previous research has demonstrated that relaxation and other cognitive behavioral variables help control occurrence of headaches. Other research has documented that group treatment is no less effective than individual therapy, and that depression is associated with migraines. However, these relationships have not been explored in inpatient settings where patients come for intensive medical interventions to treat intractable, chronic headaches.

Objective: To evaluate prospectively the contribution of a psychological self-management program to the amelioration of headache-related distress of patients with intractable migraine treated in a comprehensive, multidisciplinary, inpatient program.

Subjects: Data from 221 patients were used. The mean age was 39 years and 77% were women. The headache diagnosis for 86% of the sample was a migraine variant (chronic daily headache); the remaining 14% had a combination of chronic post-traumatic headache, cluster headaches, and facial pain.

Methods: On admission and at discharge subjects completed the Beck Depression Inventory (BDI) and a seven-day retrospective self-reporting questionnaire that assessed the frequency of severe headaches and health behavior compliance in two categories: relaxation and lifestyle modification. Each patient received intensive medical therapy including intravenous DHE-45 or other intravenous medication, or both. Cognitive behavioral treatment was delivered in five group settings per week. Training included methods of relaxation and self-monitoring of associated changes in finger temperature and self-rated subjective tension. Other topics included relaxation tapes, sleep regulation, self-pacing, exercise, and pain management skills.

Results: Adherence increased significantly for relaxation practice and lifestyle modification (diet, exercise, and sleep regulation) for headache prevention (P < 0.00001). BDI scores decreased significantly (P < 0.00001), and a greater decrease in depression by the end of the program was reported by those subjects who practiced relaxation most compared with those who practiced relaxation least.

Conclusion: Low baseline adherence rates for health behavior increased significantly during the final week of inpatient treatment. Behavioral self-management, not headache reduction, were significantly associated with patients’ reduction in affective distress. The finding that the practice of relaxation was associated with reducing depression gives credence to the importance of relaxation to the overall well-being of patients.

Comment: It was interesting to note how the BDI scores decreased during the course of hospitalization. Yes, this may have been correlated to the relaxation that was taught and encouraged during the hospitalization, but it also may be related to the fact that somebody was actually paying attention to the patient’s disorder and actively trying to help her cope with her problem. It would be good to repeat and modify this study by adding a two-week and two-month follow-up testing period. Could it be that the depression decrease only occurs during the attention-receiving inpatient period, but rises again once the patient returns to the setting from which he or she comes?