254 Headaches
The prolonged presence of headache begins to exert a psy-
chological toll on the patient over time, such that the patient be-
comes •sick and tired of feeling sick and tired.ŽThe negative
thoughts and emotions arising from the repeated experience of
headache thus can become further stressors or trigger factors in
and of themselves (referred to as •headache-related distressŽ),
serving at that point both to help maintain the disorder and to
increase the severity and likelihood of future attacks. Pointing
out the direct and indirect psychological in”uences on
headache may make it easier for the patient to understand and
accept the role of psychological factors and can often facilitate
referral for adjunctive psychological/psychiatric care when
needed (to illustrate, ask the patient which is worse, onset of a
headache when the patient is refreshed and rested or when
work and family frustrations are at a peak). This model points
out the various areas to address when interviewing headache
patients.
Implementation
Appropriate treatment implementation assumes adequate ex-
pertise in the application of the interventions selected. Be-
cause this chapter is intended for nonmedical practitioners,
the following sections will address the application and imple-
mentation of nonpharmacological, behavioral and cognitive
behavioral, interventions that have garnered empirical sup-
port to date. As previous sections have indicated, appropriate
medical evaluation cannot be overlooked and pharmacologi-
cal therapy may be the treatment of choice or a necessary
component. When pharmacotherapy is used, ongoing med-
ical assessment and collaboration with a quali“ed medical
provider is critical (Blanchard & Diamond, 1996).
A common element among all therapies is patient educa-
tion, which begins at the onset and continues throughout treat-
ment. Research by Packard (1987) reveals that information
about headache is one of the top needs of patients when
they come for treatment. Each of the following treatments
begins with an educational component that typically in-
cludes information on the etiology of headache, the rationale
for treatment, and an explanation of what is involved with
the particular treatment, as well as encouragement of active
participation on the part of the patient (Andrasik, 1986,
1990; Holroyd & Andrasik, 1982). Therapists are encour-
aged to discuss the aforementioned biobehavioral model of
headache in clear, nontechnical terms.
In the initial session emphasis is placed on the importance
of collaboration between the therapist and patient and of reg-
ular home practice to facilitate skill acquisition (Holroyd &
Andrasik, 1982; Martin, 1993). Although strongly encour-
aged, the role of home practice has received inconsistent
support in the research literature. In clinical practice, the
importance of home practice is emphasized, even though
this may often be an unexamined assumption (Blanchard,
Nicholson, Radnitz, et al., 1991; Blanchard, Nicholson,
Taylor, et al., 1991).Relaxation TrainingRelaxation training for recurrent headache disorders may take
a variety of forms. Two forms in particular have been widely
applied in the treatment of recurrent headache disorders: pro-
gressive muscle relaxation (e.g., Cox, Freundlich, & Meyer,
1975) and autogenic training (e.g., Sargent, Green, & Walters,
1973). Transcendental Meditation (Benson, Klemchuk, &
Graham, 1974) and self-hypnosis (ter Kuile, Spinhoven,
Linssen, & van Houwelingen, 1995) have also been applied,
but not extensively.
Progressive muscle relaxationtraining as applied to recur-
rent headache disorders is most often based upon the work of
Jacobson (1938) or Bernstein and Borkovec•s (1973) abbre-
viated adaptation of Jacobson•s procedures. Progressive mus-
cle relaxation may be used alone or in conjunction with
biofeedback. Typically applied during 10 sessions over the
course of eight weeks, the procedure involves therapist-
guided training of patients to alternately tense and relax tar-
get muscle groups. Patients are instructed to tense the target
muscle group for “ve to ten seconds, focusing on the sensa-
tions that result from the tension. Following the tension
phase, patients are instructed to release the tension and relax
the muscle for 20 to 30 seconds, again focusing on the sensa-
tions associated with the release of tension. The tense/relax
cycle instructions are repeated two to three times for each
muscle group. As the patient becomes pro“cient at tensing
and relaxing muscle groups, training proceeds to consolidate
muscle groups, facilitate the deepening of relaxation,
enhance abilities to discriminate among various levels of re-
laxation, and induce relaxation by recall. Patients are typi-
cally instructed to practice their relaxation exercises once or
twice daily for 20 minutes. Table 11.5 from Andrasik (1986)
and Tables 11.6 and 11.7 contain a summary of a typical
protocol.
Autogenic trainingwas “rst applied to headache disorders
(typically migraine) by Sargent et al. (1973). Autogenic train-
ing (Schultz & Luthe, 1969) involves focusing on a set of
phrases speci“cally designed to promote a desired physiologic
state. Autogenic training for headache treatment utilizes
phrases intended to elicit sensations of relaxation, heaviness,
and warmth in the entire body (face/head, trunk, and extremi-
ties) with a particular emphasis placed on warming of the
hands. Autogenic training is often employed in conjunction