252 Headaches
headache patients and chronic/frequent use of over-the-
counter medications has been reported by almost 20% of
primary care headache patients (Von Korff et al., 1995).
These potential risks, combined with the growing interest in
self management and alternative approaches, warrant the
consideration of nonpharmacological treatments. Fortu-
nately, a number of such treatments have been systematically
evaluated and have been found to demonstrate therapeutic
ef“cacy.
Nonpharmacological Treatments for Headache
There are three basic approaches to nonpharmacological
treatments for recurrent headache disorders. These ap-
proaches are designed (a) to promote general overall relax-
ation either by therapist instruction alone (e.g., progressive
muscle relaxation, autogenic training, meditation) or thera-
pist instruction augmented by feedback of various physiolog-
ical parameters indicative of autonomic arousal or muscle
tension to help “ne tune relaxation (e.g., temperature, elec-
tromyographic, or electrodermal biofeedback); (b) to control,
in more direct fashion, those physiological parameters
assumed to underlie headache (e.g., blood ”ow and
electroencephalographic biofeedback); and (c) to enhance
abilities to manage stressors and stress reactions to headache
(e.g., cognitive and cognitive behavior therapy).
Investigations of these treatments are extensive and too
numerous to review study by study. This has led recent re-
viewers to examine ef“cacy by the quantitative procedure of
metaanalyzes. The metaanalyzes conducted to date are sum-
marized in Table 11.4. Early metaanalyzes excluded very few
of the available studies, including poorly designed studies
along with expertly designed studies (the main entrance cri-
terion was a minimal sample size). More recent analyzes
have been much more selective about the studies permitted
to enter analysis. For example, the AHCPR metaanalysis
(Goslin et al., 1999) located 355 behavioral and physical
treatment (acupuncture, TENS, occlusal adjustment, cervical
manipulation, and hyperbaric oxygen) articles, 70 of which
consisted of controlled trials of behavioral treatments for
migraine. Only 39 of these trials met criteria for inclusion in
the analysis. Findings from the most recent metaanalyzes
should be considered as providing lower bound estimates of
effectiveness, under very tightly controlled conditions.TABLE 11.4 Average Improvement Rates from Separate Metaanalyzes
A. Tension-Type Headache
EMG REL EMG REL BFCT COG PHARM OTHER PTCT MDCT WTLTBlanchard, Andrasik, Ahles, 61 59 59 35 35 5
Teders, and O•Keefe (1980)
Holroyd and Penzien (1986) 46 45 57 15 4
Bogaards and ter Kuile (1994) 47 36 56 53 39 38 20 5
McCrory, Penzien, Hasselblad, 48 38 51 40 35 17 3
and Gray (2001)
B. Migraine Headache
ATFB THBF REL VMBF THBF REL EMG COG COG BF PTCT MDCT WTLTBlanchard et al. (1980) 65 52 53 17
Holroyd, Penzien, Holm, 28 44 31 57 11
and Hursey (1984)
Blanchard and Andrasik (1987) 49 27 48 43 29 26 13
Goslin et al. (1999) 37 32 33 40 49 35 9 5
EMG Electromyographic biofeedback, generally provided from the frontal/forehead muscles.
REL Relaxation therapy, generally of the muscle tensing and relaxing variety.
BFCT Biofeedback control procedure, generally false or noncontingent biofeedback.
COG Cognitive therapy, stress coping training, or problem-solving therapy.
BF EMG or thermal biofeedback.
PHARM Various medications, ranging from aspirin and nonsteroidal in”ammatories to prophylactics to narcotics.
OTHER Various approaches, other than BF, REL, or COG.
PTCT Psychological or pseudotherapy control procedure.
MDCT Medication control procedure; results taken from double blind placebo controlled medication trials.
WTLT Waiting list control procedure; no treatment.
ATFB Thermal biofeedback augmented by components of autogenic training, as developed at the Menninger Clinic.
THBF Thermal biofeedback by itself.
VMBF Vasomotor biofeedback provided from the temporal artery.
*Amitriptyline alone.