Behavioral management of the triggers of recurrent headache: A randomized controlled trial

• The standard advice to headache sufferers is to avoid all headache triggers.
• Recent findings suggest that this may lead to sensitization to the triggers.
• This study evaluates advice to avoid versus exposure to achieve desensitization.
• Avoidance did not lead to significant reductions in headaches or medication.
• Exposure was associated with significant reductions in headaches and medication.

This study was designed to evaluate the traditional advice to headache sufferers to avoid all triggers (‘Avoidance’), and a novel approach to trigger management (Learning to Cope with Triggers – ‘LCT’) that included graduated exposure to selected triggers to promote desensitization. Individuals (84F, 43M) with migraine and/or tension-type headache were assigned randomly to one of four groups: Waiting-list (Waitlist); Avoidance; Avoidance combined with cognitive behavior therapy (Avoid + CBT); and LCT. Changes in headaches and medication consumption (in parentheses) from pre- to post-treatment were (a minus sign indicates improvement): Waitlist, +11.0% (+15.4%); Avoidance, −13.2% (−9.0%); Avoid + CBT, −30.0% (−19.4%); and LCT, −35.9% (−27.9%). Avoidance did not differ significantly from Waitlist on headaches or medication use, but LCT differed significantly from Waitlist on both measures. Avoid + CBT significantly differed from Waitlist on headaches but not medication consumption. In summary, the study failed to find support for the standard approach to trigger management of advising avoidance, but LCT emerged as a promising strategy. LCT resulted in greater improvement than the other three conditions on all measures of headaches and medication consumption, and was the only treatment condition that significantly differed from the waiting-list control condition in terms of treatment responder rate (50% or greater reduction in headaches) and medication consumption.