STOWE, VT—Three independent dimensions of headache impact were described by Holroyd and colleagues about six years ago—pain, disability, and affective distress. The latter of those dimensions was explored in depth by Steven M. Baskin, PhD, in an effort to find ways to prevent behavioral morbidity in headache, the subject of a presentation he delivered at the 15th Annual Headache Symposium.

Individuals with affective distress are not necessarily always experiencing stress, explained Dr. Baskin, Co-Director of the New England Institute for Behavioral Medicine in Stamford, Connecticut. “But under certain emotional conditions, they might have a lot of distress, and that might affect how you manage headache and it might actually chronify the process,” he said.

A major goal in assessing headache history is to identify important risk factors such as use of caffeine and alcohol, lack of exercise, and medication overuse. The clinician should also seek information on the patient’s mood, anxiety levels, coping skills, and environmental risk factors.

Dr. Baskin emphasized the need for a clinician to assess sleep history; he cited the example of a sleep apnea patient with chronic headaches who is now doing better overall on continuous positive airway pressure therapy. For gauging disability, it can be useful to determine not only if headache patients are able to get to work but also if they can be productive once they are there. “Presenteeism is an interesting concept,” remarked Dr. Baskin. “They are at work, but are they actually getting anything done?”

LOCUS OF CONTROL

The headache history is likely to reveal an aspect of personality that profoundly influences the course of headache—whether the patient has an internal or external locus of control. While those with an internal locus of control perceive life events and circumstances as resulting from their own actions, those with an external locus of control are just the opposite. “Things are beyond their control, and they come in with a fix-me, helpless kind of attitude,” related Dr. Baskin. “There are some data to show that people with an external locus of control have a more problematic course.” These patients are also more prone to psychiatric problems.

Dr. Baskin said that he tries to guide these patients toward a more internal locus of control by teaching them how to be more action oriented and more realistic regarding what their expectations of headache therapy are. He also makes sure to treat any depression or other comorbid psychiatric conditions that are present, because failure to do so increases the risk of headache relapse and can also lead to continued psychosocial impairment, as well as contribute to headache treatment refractoriness.

DRUGS OF CHOICE

β-Blockers should be used with caution in headache patients who are depressed, warned Dr. Baskin. “I have seen some cases where β-blockade has clearly made their sleep and mood worse,” he said. Headache patients with depression may respond well to selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants, but bipolar disorder must be ruled out before such a drug is started, since it may precipitate mania. Since tricyclic antidepressants are good preventive headache medications and the data are not very good for SSRIs in headache prevention, Dr. Baskin continued, it is helpful to treat comorbid depression with a combination of SSRIs and low-dose tricyclic antidepressants.

Caution is also necessary in prescribing benzodiazepines, due to the potential for abuse, addiction and headache potentiation if they are taken chronically. Other possible choices for headache patients with anxiety disorders include tricyclic antidepressants, SSRIs, biofeedback-assisted relaxation training, psychotherapy, and sometimes, β-blockers.

Divalproex sodium can be an especially cost-effective option for headache patients with bipolar disorder, because it may suppress the latter condition and lessen migraine pain. But patients with hypomania or mania are best treated with a neuroleptic, an anticonvulsant, or possibly, lithium. Combined therapy requires a psychiatrist’s supervision because of its complexity, stressed Dr. Baskin. Failure to adequately treat comorbid psychiatric disorders worsens headache prognosis and increases utilization of medical services and is a factor in sustaining medication overuse, he said.

MEDICATION OVERUSE

Early treatment of headache symptoms is important, but it is another area requiring prudence since it can lead to medication overuse, which increases the chance of rebound headache. A potential mechanism underlying medication overuse: Headache patients are sometimes classically conditioned by their unpredictable, severe pain to take analgesics earlier in an attempt to avoid the pain, Dr. Baskin observed. That is, the anticipation of another migraine causes a phobic reaction in some patients.

Biofeedback-assisted relaxation therapy can help to prevent this, research suggests. In a study of chronic daily headache with associated medication overuse, biofeedback was associated not only with reduced analgesic use but also with a decline in number of headache days and significant reductions in the risks of headache relapse and rebound headache.

Compared with those patients who received only drug therapy, the biofeedback group had significantly better outcomes at three years but not at one year. The five-year data, as yet unpublished, appear to be particularly dramatic, said Dr. Baskin.

While it is common for headache patients to overmedicate, they also have substantial nonadherence rates. Indeed, according to Dr. Baskin, 45% drop out of treatment entirely. Furthermore, 40% do not go for follow-up, 50% are nonadherent with medications, up to 70% fail to make optimal use of abortive medications, and only 24% are using their medications as directed after one year.

“The number one factor in terms of nonadherence is this affective distress and comorbid psychiatric illness,” Dr. Baskin stated. “If you do not treat it, these patients are going to be less adherent to a headache drug regimen.” It is vital, too, he maintained, to determine what patients expect from treatment, as well as to actively listen to them, educate them, involve them in decision making, and create as simple a treatment regimen as possible. Dr. Baskin concluded that clinicians seeing headache patients need to perform a comprehensive behavioral/psychologic assessment. Pain, disability, and affective distress need to be independently evaluated and medication adherence and overuse issues should be assessed. Affective distress, somatization, and psychiatric comorbidity, he emphasized, need to be aggressively treated pharmacologically and psychologically.

—Timothy Begany

Suggested Reading
Baskin SM, Weeks RE. The biobehavioral treatment of headache. In: Moss D, McGrady A, Davies T, Wickramasekera I, eds. Handbook of Mind-Body Medicine in Primary Care. Thousand Oaks, Ca: Sage;2003:205-222.
Grazzi L, Andrasik F, D’Amico D, et al. Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: outcome at 3 years. Headache. 2002;42:483-490.
Holroyd KA, Malinoski P, Davis MK, Lipchik GL. The three dimensions of headache impact: pain, disability and affective distress. Pain. 1999;83:571-578.
Low NC, Du Fort GG, Cervantes P. Prevalence, clinical correlates, and treatment of migraine in bipolar disorder. Headache. 2003;43:940-949.
McGrady AV, Andrasik F, Davies T, et al. Psychophysiologic therapy for chronic headache in primary care. Prim Care Companion J Clin Psychiatry. 1999;1:96-102.
Page LA, Howard LM, Husain K, et al. Psychiatric morbidity and cognitive representations of illness in chronic daily headache. J Psychosom Res. 2004;57:549-555.
Sheftell FD, Atlas SJ. Migraine and psychiatric comorbidity: from theory and hypotheses to clinical application. Headache. 2002;42:934-944.

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