Behavioral Treatment Planning 257headache disorders, there is also evidence to suggest that
stress, appraisal of stress, and coping play a signi“cant role
in recurrent headache disorders (Holm, Holroyd, Hursey, &
Penzien, 1986; Lake, 2001). Theoretically, cognitive behav-
ioral therapies may work by altering cognitive appraisals/
expectancies, stress responses, or cognitive/behavioral cop-
ing responses, although the speci“c causal relationships
between stress and headaches and cognitive therapies and
headaches remain unclear (Morley, 1986).
Much of the empirical study of cognitive behavioral
interventions for recurrent headache disorders have
adapted the traditional cognitive behavioral framework of
Meichenbaum•s stress inoculation training as applied to pain
(Meichenbaum, 1977; Turk, Meichenbaum, & Genest, 1983)
or Beck•s cognitive therapy (Beck, Emery, & Greenberg,
1985; Beck, Rush, Shaw, & Emery, 1979). These traditional
cognitive-behavioral therapies have been adapted speci“-
cally for the treatment of recurrent headache disorders by
Holroyd and Andrasik (1982) and Holroyd, Andrasik, and
Westbrook (1977). It should be kept in mind that cognitive
behavioral therapies for headache are most often applied in
the form of a •treatment packageŽ that may include a number
of the other approaches discussed previously.
In CBT patients are taught a rationale that suggests that
learning to identify and modify cognitions will mediate the
stress-headache relationship. Unfortunately, empirical inves-
tigation of these assumptions is very limited, as are data to
support the validity of these assumptions. This led Morley
(1986) to conclude that •this approach to treatment is open to
the criticism that the therapy works because of a convincing
rationale and not because the rationale is essentially correctŽ
(p. 317). This conclusion still applies. Although CBT has
been shown to be superior to no treatment and to be as good
as (if not superior to) other effective treatments for headache,
it is also unclear whether CBT is superior to a credible atten-
tion placebo (Blanchard, 1992). While it is clear that much
more investigation is required before this rationale can be
claimed as validated, the data are also clear that cognitive be-
havioral therapies possess ef“cacy in the treatment of recur-
rent headache disorders, even if the mechanisms of action are
poorly understood.
Holroyd and Andrasik (1982) identify three general phases
of CBT for headache disorders, including: education, self-
monitoring, and problem-solving or coping skills training.
For the most part, cognitive behavioral approaches to
headache disorders are fairly consistent in their emphasis on
education and self-monitoring. It is within the last phase that
much of the variability exists.
Once the rationale has been explained in suf“cient detail,
CBT for headache disorders moves quickly into a very
detailed form of self-monitoring. Patients are taught to
monitor and record the factors that precede, accompany, and
follow stressful situations and headaches. Patients are taught
to monitor their thoughts (cognitions), feelings (emotions),
behaviors, and sensations. This functional analysis of an-
tecedents, concomitants, and consequences is intended as a
means of identifying modi“able aspects of headache and
stress. Emphasis is often placed on the antecedents and con-
comitants of headache and stress, particularly cognitive and
behavioral antecedents and concomitants because of the as-
sumption that these may be amenable to modi“cation.
The remainder of cognitive behavioral therapy focuses on
modifying those factors that appear to be related to headache
activity and stress. This phase of the therapy may vary
substantially. A number of strategies and techniques may be
used to modify the factors that were identi“ed through self-
monitoring. Some of the most common cognitive strategies
applied include cognitive restructuring and reappraisal (in
the tradition of the Cognitive Therapy of Beck or Rational
Emotive Therapy of Ellis) and the use of coping self-
statements (in the tradition of Meichenbaum•s Stress Inocula-
tion Training). Common to each of these approaches is the
identi“cation and revision of maladaptive cognitions. Using
any of these approaches, the therapist assists the patient in the
review of self-monitoring data by helping the client identify
maladaptive cognitions and challenge them effectively.
Therapists may also assist in the identi“cation of maladaptive
behavioral responses to stress and provide training and sup-
port in the use of problem solving strategies to identify more
adaptive behavioral responses to stress and headache.BEHAVIORAL TREATMENT PLANNINGThe empirical treatment outcome literature, pharmacological
and nonpharmacological, provides a useful starting point for
treatment planning with an individual patient. In addition to
reporting on the overall ef“cacy of various treatments, this
literature also offers some insights into individual factors
that increase or decrease the likelihood of a clinically signi“-
cant treatment response. Unlike treatment outcome studies
that are con“ned by the restraints of empirical rigor for the
purpose of hypothesis testing and maintenance of internal
validity, clinical treatment of patients presenting with recur-
rent headache disorders must rely on sound clinical judgment
and careful selection of interventions that are most likely to
provide the best treatment outcome for the individual.
Whereas treatment outcome studies utilize a somewhat stan-
dardized approach, optimal clinical treatment is not always
suited by a •one-size-“ts-allŽ stance. The following sections