Tension headaches and migraines

Headaches and migraines are debilitating and costly. For people who suffer with them, it is understandable that they will want to try anything that might work. An easy fix would be lovely and pursing this is an understandably tempting option. Like most other chronic conditions however, the magic silver bullet to reduce the problem is rarely going to come from a single modality treatment such as medication or manual therapy.
Getting patients to acknowledge that there might be a mind body connection in something like back pain might be tricky. We might be able to see that there are some obvious contributors and getting that message across to the patient can be a tough but important step in making progress. However headaches is an obvious one isn’t it? It is a metaphor for stress, we even have a label for one of the more common headaches – tension type headache. It’s not always an easy sell to get this one acknowledged either. Patients will often insist that if they could just get rid of the headache, their problems would be easier to tackle or wouldn’t exist. I have been guilty of this myself – so focused on a tension headache being the cause of my heightened stress levels, chasing the quick fix with the idea that taking the headache away is the number one priority. In effect – not being able to see the wood for the trees and that the heightened stress levels are majorly contributing to the headache situation. In my case, it has sometimes taken a treating practitioner to point out this situation to me. Once this has been pointed and I have acknowledged that indeed, I am under the pump and need to address the situation, the headaches invariably go. Nothing like a personal foray into pain to help boost a practitioner’s empathy and understanding!
The science is increasingly telling the story that a bigger picture approach is the key to getting good reductions in frequency and severity of chronic headaches, as well as improving the functional losses that often accompany headaches, such as days off work.

Cognitive behavioural approaches to headaches are well represented in the literature and are acknowledged by the pain community as relatively low cost, low side effect treatment for tension type headaches and migraines.(1) A study by Paul Martin and colleagues in 2007 took 51 headache and migraine suffers and allocated them into a cognitive behavioural therapy (CBT) group, a biofeedback group and a control group. The CBT group had 8, 1 hour sessions and the intervention was found to reduce headaches an average of 68% following treatment. This was compared to a 56% reduction in the biofeedback group and 20% reduction in the control group. Furthermore, in the CBT group, the headaches continued to decrease to a 12 month follow up, whereas the other groups did not. The CBT group also had a 70% reduction in medication use.(2)

Mindfulness based approaches work really well in the chronic pain setting as part of a bigger picture approach(3). A recent study published in the Clinical Journal of Pain, looked at applying Mindfulness-based stress reduction in combination with CBT approaches in treating chronic headaches. The study demonstrated that the approach gave good outcomes for pain acceptance, pain catastrophising and helped to reduce pain interference (or functional losses to due pain). This was a pilot study but showed some very promising results. (4)

Exercise approaches for tension headache and migraine have been shown to be helpful and regular exercise is often recommended in migraine treatment. For a small proportion of the migraine population however, exercise can act, or be perceived to act as a trigger for a migraine, perhaps making them avoid exercise. A study published in Cephalgia in 2011, compared three groups of intervention for migraine sufferers – an exercise group, a medication group (Topirimate –a prophylactic medication for migraine) and a relaxation group. Good reductions in migraine frequency were seen in all three groups with no statistically significant difference between them. The exercise used was a 40 minute session of indoor cycling three times a week. Of that 40 minutes, 15 minutes was a warm up, 20 minutes was the main exercise component and 5 minutes was a cool down. It terms of risks versus benefits, this shows huge potential as it is easy to implement and has virtually no side effects, compared to some of the mild side effects seen with the medication group.(5)

So whilst we might not be able to make a big impact on these types of headaches with our hands in the longer term, we can certainly be incorporating these approaches in our practice, even if it is in the form of case management – where we oversee the treatment approaches and refer to appropriate practitioners. Alternatively you may be able to implement exercise approaches either within your clinic or together with the patient as a home exercise program. Starting patients on mindfulness meditation is a no-brainer and essentially is a free kick at goal for the results you can achieve versus the effort and cost to implement it. You can use something like the smiling mind app and website to help get things going.

You may be able to refer your patient to a psychologist for some cognitive behavioural therapy.  Our listening ears and a good referral base of practitioners in this case are the thing that is most likely going to give good outcomes for the patient. The impact that this can have should not be underestimated.

1. Rains, J., Penzien, D., McCrory, D., & Gray, R. (2005). Behavioural treatment: History, review of the empirical literature and methodological critique. Headache, 45(Suppl.2), S92-109.
2. Martin, P., Forsyth, M., & Reece, J. (2007). Cognitive-behavioural therapy versus temporal pulse amplitude biofeedback training for recurrent headache. Behavior Therapy, 38, 350-363.
3. Mars, T., & Abbey, H. (2010). Mindfulness meditation practice as a healthcare intervention: A systematic review. International Journal of Osteopathic Medicine. 13(2), 55-66.
4. Day, M., Thorn, B., Ward, C., Rubin, N., Hickman, S., Scogin, F., & Kilgo, G. (2014). Mindfulness-based cognitive therapy for the treatment of headache pain. A pilot study. Clinical Journal of Pain, 30(2), 152-161.
5. Varkey,E., Cider, A., Carlsson, J., & Linde, M. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topirimate as controls. Cephalgia. 31(14), 1428-1438.