258 Headaches
describe some of the individual factors that have been found
to be related to treatment outcome and that can be useful in
determining which of the numerous options for treatment
might be particularly useful for an individual patient. These
factors include: headache type, frequency, and chronicity;
age and gender; comorbid psychological disorder or distress;
environmental factors; and treatment history. Other factors,
such as patient preference and cost effectiveness, have not
received as much empirical attention, but these are nonethe-
less important when considering treatment options. While
much of the empirical literature has examined •intensiveŽ in-
dividual therapy formats (typically 8 to 12 sessions), other
methods of treatment delivery merit consideration, including
reduced therapist contact and group treatments.
Headache Type, Frequency, and Chronicity
Both tension-type and migraine headache respond well to
pharmacological and nonpharmacological treatments. With
regard to nonpharmacological interventions, both headache
types bene“t from relaxation training and cognitive behav-
ioral interventions. Although thermal biofeedback is more
widely applied to migraine headache and EMG biofeedback
is more widely applied to tension-type headache, there is
evidence to suggest that EMG biofeedback is also useful for
migraine headache. Patients with mixed migraine and tension-
type headaches also respond to the treatments discussed
above, although typically not as well as those with •pureŽ
migraine or tension-type headaches. Cluster headache does
not appear to respond as well to behavioral treatments. Data
are less clear for headaches that are associated with menses.
Headaches resulting from trauma require intensive, multi-
component treatment.
Patients with chronic daily or near daily, high intensity
headache do not respond well to behavioral interven-
tions alone (Blanchard, Appelbaum, Radnitz, Jaccard, &
Dentinger, 1989). However, chronic daily headache has been
found to be unrelated or positively related to the use of
abortive and prophylactic medications (Holroyd et al., 1988).
These data suggest that medications may be the “rst-line
treatment for patients with chronic/daily or almost continu-
ous headache.
Age and Gender
Young adults generally respond better to nonpharmaco-
logical interventions than older adults and women generally
respond better than men (Diamond, Medina, Diamond-Falk,
& DeVeno, 1979; Diamond & Montrose, 1984). Geriatric
headache patients have been found to be less responsive to
standard behavioral treatment protocols (Holroyd & Penzien,
1986). When protocols are adjusted to compensate for any
age-related declines in information processing capabilities,
however, outcomes become much more favorable (e.g.,
Arena, Hannah, Bruno, & Meador, 1991; Arena, Hightower, &
Chong, 1988; Nicholson & Blanchard, 1993).
Behavioral treatments have been found to be especially
effective for pediatric headache sufferers (Attanasio,
Andrasik, Burke, Blake, Kabela, & McCarran, 1985;
Hermann, Blanchard, & Flor, 1997; Hermann et al., 1995;
Holden et al., 1999). Although no direct comparisons of child
and adult headache patients have been conducted within a
single study, a recent metaanalyzes, drawing on nearly 60
existing separate child and adult studies, revealed that
children improved at a much greater level when treated in a
similar fashion with either temperature or EMG biofeedback
(Sara“no & Goehring, 2000).Treatment HistoryPatients who have a history of habituation to medication,
consume large amounts of medication, are suffering from
drug-induced headaches, or are particularly refractory tend to
respond less well to behavioral interventions (see earlier sec-
tions). In these situations, detoxi“cation may need to be ac-
complished before nonpharmacological intervention; some
have suggested that nonpharmacological interventions be im-
plemented during a gradual reduction and discontinuation of
the offending medication in an effort to reduce the high
dropout rates associated with drug withdrawal procedures
(Gauthier et al., 1996; Grazzi et al., 2001). In these cases, pre-
vious treatment provides clear contraindications for speci“c
pharmacological interventions and begins to suggest alter-
nate strategies that may be helpful to refractory patients.
Blanchard, Andrasik, Neff, et al. (1982) examined a
stepped-approach to treating diverse headache patients.
Initially, all subjects (tension-type, migraine, or both com-
bined) were treated with relaxation training, resulting in a
substantial reduction in headache for all three headache types
but particularly for tension-type headache sufferers. Those
subjects who did not respond well to relaxation training were
subsequently treated with biofeedback (thermal for pure mi-
graine or combined headache; EMG for tension-type). The
subsequent biofeedback treatment resulted in further signi“-
cant reductions, particularly for combined headache patients.
These “ndings suggest that relaxation training is useful for all
three types of headaches but also emphasize the value of
biofeedback for those who do not respond initially to relax-
ation training (especially those with migraine or mixed
headaches). These results further suggest that relaxation and