Handbook of Psychology

260 Headaches

factors, which might be serving to maintain headache pain
behavior and to be aware of how he or she may subtly begin to
contribute to the headache problem itself.
When such environmental factors are in evidence, thera-
pists are urged to lessen (gradually) attention given to pain
symptoms, encourage and reinforce efforts to cope with
head pain (ask, •How are you trying to manage your
headaches?Ž rather than, •How is your headache today?Ž),
encourage the inactive patient to set daily goals and stick to
them despite the pain level, and arrange for needed anal-
gesic medications to be taken on a time-contingent, as
opposed to a pain-contingent, basis. Fordyce (1976) presents
a detailed format for questions to ask of patients and family
members being treated for chronic pain, which are also
appropriate to consider when evaluating headache patients.
In the only examination of its type, Allen and Shriver
(1998) found that adding parent training in pain behavior
management to standard biofeedback treatment signi“cantly
incremented effectiveness over biofeedback alone for ado-
lescent migraineurs.

Patient Preference and Cost Effectiveness

To date, there are no clear empirical data to suggest whether
patient preference is predictive of treatment outcome.
Nonetheless, this factor should always be considered when
providing clinical treatments or interventions to individual
patients. As a matter of course, compliance and cooperation
are likely to be in”uenced by patient preference for treatment
type; to ignore this would be a serious error.

Treatment Algorithms

Holroyd et al. (1998) provide treatment algorithms for the
integration of behavioral and pharmacological therapies for
recurrent migraine and tension-type headache that clinicians
and researchers may “nd useful. While these algorithms have
not been empirically tested, they are based on the extensive
empirical literature previously described and represent a set
of empirically supported decision-making guidelines.
These authors suggest the use of both pharmacological
and nonpharmacological treatments for migraines that are
frequent and/or severe. For migraine headaches that are
less frequent and unaccompanied by psychological prob-
lems, factors such as patient preference, previous treatment
experience/outcome, and cost may be used to select either
pharmacological or nonpharmacological methods of treat-
ment as a “rst line treatment. Should the initial choice fail to
result in a satisfactory outcome, the alternate strategies may
then be used as a supplement or second-line treatment.

For tension-type headaches, Holroyd et al. (1998) con-

sider behavioral interventions to be the treatment of choice.

However, if the headaches are unremitting or complicated by

signi“cant psychological disturbance, the use of antidepres-

sant medication should be considered early. Minimal thera-

pist contact interventions (see next) may be tried initially,

with more intensive treatments applied if initial efforts

are unsuccessful. If the addition of other behavioral and

cognitive behavioral interventions fails to result in a satis-

factory outcome, then prophylactic medications should be

considered.

Treatment Format and Delivery

In addition to individual characteristics of patients that may

predict response to treatment and aid in the selection of ap-

propriate intervention(s), treatment planning also involves de-

cisions about treatment format and delivery. Practical factors,

such as limited patient and/or therapist time, cost prohibitions,

and limited geographical access, may preclude intensive indi-

vidual therapies (Rowan & Andrasik, 1996). This has led

researchers to explore more economical alternatives.

Minimal Therapist Contact Interventions

The main alternate delivery approach investigated to date re-

tains a 1:1 focus, but markedly reduces clinician contact by

supplementing treatment with instructional manuals and cas-

settes that subjects utilize on their own at home or at work.

The •prototypicalŽ minimal therapist contact intervention in-

cludes an initial in-of“ce session, a mid-treatment of “ce ses-

sion, and a “nal session with the therapist over the course of

eight weeks or so, plus the use of two to three telephone con-

tacts in between. These intermittent visits and calls are de-

signed to keep patients engaged in treatment and to offset the

high dropout rates that have occurred with entirely self-help

approaches (Rowan & Andrasik, 1996). Thus, while time

spent at the of“ce and with the therapist is signi“cantly re-

duced (as are costs), time investments by the patient are still

extensive.

There is a substantial body of literature to suggest that non-

pharmacological interventions may be effectively applied in

cost-effective, minimal therapist contact formats and that

these formats rival more •intensiveŽ interventions, with both

adults and children (Haddock et al., 1997; Rowan & Andrasik,

1996). Furthermore, the bene“ts appear to be well maintained

over time (Blanchard et al., 1988). Minimal therapist contact

interventions have been found to have attrition rates similar to

more intensive therapies and to produce two to six times more

headache reduction per therapist hour than more intensive