Psychological Approaches to Headache

As a group, headache disorders are painful and disabling, impacting the lives of people with headache across multiple domains and reducing their ability to be productive and satisfied members of society. The majority of work examining psychological approaches to headache has occurred within the two most prevalent primary headache disorders: migraine and tension-type headache. Recent epidemiological studies have demonstrated prevalence rates for episodic migraine of 12% across the United States population, including 18% of women and 6% of men. Chronic migraine affects a smaller proportion of the United States population (1 2%), with a higher proportion of women to men similar to episodic migraine, but can be far more disabling because of its chronic nature, and because it is less responsive to available treatments. Migraine is associated with high levels of disability, and can interfere with the individual’s functioning across domains. Migraine has been ranked as the seventh specific cause of disability worldwide, and accounts for more than 1% of years lived in disability. Migraine occurs during the most productive years of life, and has a higher prevalence in women. Migraine can reduce the capacity of individuals to function in social and work environments both during the period of the headache attack (during which a person with migraine may need to completely withdraw to a dark, quiet room), as well as between attacks, during which time a person with migraine may experience anxiety about potential migraine onset and restrict their activities to avoid migraine onset. A burgeoning literature on stigma suggests that migraine patients report greater disease-related stigma than do those with epilepsy, and that much of this stigma is related to work-related productivity, and can even change decision-making about taking acute migraine treatment. Tension-type headache is a painful condition characterized by episodes of mild to moderate bilateral pressing head pain. Most people experience episodes of tension-type headache at some point in their lives. However, a minority of individuals report experiencing tension-type headache on 15 or more days per month, or chronic tension-type headache. As with chronic migraine, chronic tension-type headache is far more disabling than episodic tension-type headache, and can be less responsive to treatment. Psychological factors have been considered integral to our understanding of headache since the first recorded information about headaches. The term “psychological factors” encompasses a broad range of topics that may contribute to headaches including: patient behaviors during and in-between headache attacks; patient thoughts and beliefs about illness and headaches; and, characteristics of the environment in which patients live and work. This chapter will describe our current understanding of the role of psychological factors in headache disorders. First, we will review the role of trigger factors and their avoidance in the management of headache disorders, as well as the role of behaviors, thoughts, and psychiatric comorbidities in the onset and maintenance of headache disorders. Then, we will examine the contribution of psychological factors to medical treatment of headache disorders, including medication adherence and patient physician communication. It should be noted that a large proportion of people with migraine manage their headaches without the assistance of prescription medications; thus, those who seek medical consultation likely have a slightly