Summary and Future Directions 261therapies (thus af“rming their cost-effectiveness). Factors
that predict response to such minimal contact interventions
are less clear than those that have been previously discussed
for more •intensiveŽ treatments.
Minimal therapist contact interventions have both advan-
tages and disadvantages. Some of the advantages include
reduced therapist time and costs to the patient, expanded
accessibility of treatment, reduced scheduling demand, and
reduced patient apprehension. Disadvantages include an in-
crease in the time commitment and possibly a need for greater
motivation on the part of the patient (Andrasik, 1996).
Researchers have begun to explore the feasibility of admin-
istering behavioral treatments to large numbers of patients, via
mass media and the Internet. Researchers in the Netherlands
(de Bruin-Kofman, van de Wiel, Groenman, Sorbi, & Klip,
1997) used television and radio instruction to supplement
home-study material on headache management. Favorable re-
sults were obtained for the small sample (n271) that was
available to participate in the outcome analysis, however this
was just a fraction of the people who purchased the self-help
program (approximately 15,000). The “rst Internet-based
study was centered at the worksite and was implemented via
computer kiosks (Schneider, Furth, Blalock, & Sherrill,
1999). In the second study, patients accessed the Web from
terminals at home (Ström, Pettersson, & Andersson, 2000).
Modest improvements occurred, but attrition was consider-
able (greater than 50%) in both investigations.
Group Treatment
Napier, Miller, and Andrasik (1997...1998),upon examining
the limited investigations of behavioral and cognitive behav-
ioral group interventions for recurrent headache, offered the
following conclusions. Although only one study directly com-
pared individual versus group delivery (Johnson & Thorn,
1989), the clinical outcomes for group treatment appeared to
rival those reported for individually administered treatments.
Subject retention rates were similar as well. Time devoted to
group treatment varied considerably, ranging from a low of
270 minutes (or 4.5 hours) for a minimal contact approach to
900 minutes (or 15 hours) for an intensive, interdisciplinary
approach. Group sizes ranged from 2 to 15 participants and
utilized 1 to 2 therapists. The only study that directly investi-
gated the role of therapist experience found it was signi“-
cantly related to clinical outcome (Holroyd & Andrasik,
1978). These limited data suggest that group treatment is as
effective as individual treatment for recurrent headache disor-
ders. Once again, group treatment may be less expensive than
individual therapy. However, group treatment also requires
greater scheduling demands and may pose some of the same
disadvantages as individual treatment, such as demands on
patient and/or therapist time, cost prohibitions, and limited
geographical access.SUMMARY AND FUTURE DIRECTIONSIndividual studies, metaanalytic analyzes, and task force
reviews have shown that a number of behavioral treatments
(relaxation, biofeedback, and CBT) are ef“cacious for
uncomplicated forms of migraine and tension-type headache,
that improvement rates appear to rival those for pharmaco-
logical treatments, and that certain treatment combinations
can be more ef“cacious than single modality approaches.
Researchers continue to explore the boundary dimensions for
who is and who is not an ideal candidate for behavioral treat-
ment. People experiencing cluster, menstrual, posttraumatic,
drug-induced, or daily, unremitting headaches or certain
comorbid conditions present special challenges that can
require integrative, multidisciplinary, and intensive treatment
approaches. Although much has been accomplished since
behavioral researchers entered the headache arena approxi-
mately 30 years ago, the battle has only begun. Much addi-
tional research is needed, and we conclude the chapter with
brief mention of likely directions this research will take.
Researchers have just begun to realize the advantages of
computers and the Web for facilitating both assessment and
treatment. Pocket computers make it possible to monitor when
ratings are actually made, administer prompts when data are
incomplete, collect volumes of data in a relatively easy and ef-
“cient manner, transmit data directly to the research/clinic site,
and communicate interactively with the therapist or researcher
(Holroyd, in press). Web- and CD-Rom-administered treat-
ments have the potential to reach patients that heretofore could
not or would not seek treatment. Folen, James, Earles, and
Andrasik (2001) have shown that it is possible to use the Inter-
net to transport biofeedback treatment to remote sites that lack
the needed expertise. Particular challenges in these approaches
will be ensuring adequate medical evaluation and follow-up,
dealing with emergencies and crises, and resolving issues
related to practicing across state-licensing boundaries.
Although it is clear that certain behavioral treatments are
ef“cacious, the mechanisms by which they operate are not
well understood. This is not so surprising, considering that
the etiologies of headache were not all that clear until re-
cently. Accounts of pathophysiology for both of the major
forms of headache have shifted from peripheral and vascular
models to models that focus on central nervous system dys-
function (central sensitization for tension-type headache and
central excitability for migraine). Recognition of this will