Behavioral management of headache

Most clinicians agree that biobehavioral factors are important considerations in the assessment and treatment of patients with headache. A biobehavioral model underscores the need to abandon a traditional organic vs psychogenic explanation to account for the development and maintenance of head pain. Conditions that control pain symptoms may become multidimensional because they involve cognitive, emotional, and behavioral factors as well as biological processes. The interplay of these variables becomes an even more important treatment issue should the frequency of a patient's headaches increase, if there is increased disability secondary to headaches, and/or there is inadequate response to usually effective treatment. Patients also may present with comorbid psychiatric disorders and other concerns in addition to or secondary to their head pain. Comprehensive treatment involving pharmacologic and behavioral modalities is necessary for effective management of head pain in these patients with refractory head pain and more complex headache histories. The present article will discuss various behavioral factors that the headache practitioner should consider when making a headache diagnosis and when formulating a treatment strategy. This discussion will include the philosophy of behavioral treatment and definition of treatment goals. Behavioral treatment considerations (ie, targets for behavioral change) will be identified as ongoing treatment variables and presented as “treatment pearls.” Finally, a model of an evidence-based, behavioral intervention will be described.