July, 2006

Prevalence and Costs
More than 45 million Americans have recurring headaches, and 28 million of them have recurring migraines (NINDS, 2002). Americans miss more than 156 million workdays a year due to migraines alone (NINDS). Students miss 329,000 schooldays per month due to migraines Mack and Mack, 2004). These missed workdays and the costs of associated medical benefits represent a loss to industry of $50 billion annually (Solomon, Cady, and Klapper, 1997). Headaches are also responsible for 10 million physician visits a year in the U.S.A. (NINDS).

What is Headache?
Headache is a general term used to describe head pain. The pain can occur in the blood vessels and muscles of the scalp, face, or neck, in the tissue around the brain, or in the attaching structures at the base of the brain. Of the many types of headache, three are the most common. Tension or muscle contraction headaches are usually caused by fatigue, stress, or environmental factors.

Migraines are throbbing headaches that can last for hours or days. They usually affect one temple or side of the head, and are often accompanied by nausea, vomiting, and light/noise sensitivity. Cluster headaches are appropriately named because they occur in clusters. They are characterized by short periods (usually 30 to 40 minutes) of intensely excruciating head pain that can recur several times a day, often continuing for months at a time.

Medical Treatment of Headache
The classification of headache usually determines the treatments. For various headache conditions, over-the-counter or prescription pain medications (analgesics) are often used. Other approaches include various classes of prescription medications, including antidepressants, NSAIDS, antihistamines, anti-emetics, serotonin receptor blockers and vaso-constrictors, serotonin 1-D receptor agonists, triptan drugs, beta-blockers, ergot alkaloids, lithium, corticosteroids, calcium channel blockers, and anti-seizure medications.

Non-Pharmacologic Treatment Including Imagery
Lifestyle changes, including avoiding headache triggers, relaxation, diet, and exercise can lower stress and fatigue levels, and reduce or even prevent muscle contractions. In several studies, guided imagery, which combines deep relaxation with positive suggestion, has proven cost effective in decreasing the number, intensity, or duration of headaches, and/or increasing patients’ ability to cope with them (Andrasik, 1990; Blanchard, Andrasik, et al, 1986; Blanchard, Jaccard et al, 1985; Ilacqua, 1994; Olness, MacDonald and Uden, 1987; Reid and McGrath, 1996).

For example, researchers studied a group of 260 patients with tension-type headaches (Mannix, Chandurkar, et al, 1999). Among those in the imagery group, 21.7% reported headaches “much improved,” compared to 7.6% of the control group. The authors of a 2003 review of the literature concluded that there is “considerable evidence” of the effective of mind-body techniques such as imagery, relaxation, hypnosis, CBT in the treatment of headaches (Astin, Shapiro, et al, 2003). In another review, researchers concluded that learning to relax and reduce stress may be just as effective in reducing headaches as taking medication (Penzien, Rains, and Andrasik, 2002). Autogenic training reduced frequency of headaches (both tension and migraine) and reduced need for medication in its users (Zsombok, Juhasz, et al, 2003).

In a 2004 review, relaxation and thermal biofeedback was found helpful for migraines, while relaxation and muscle biofeedback was effective as a stand-alone or adjunctive for tension headaches (Astin, 2004).

In another review, researchers at the University of Mississippi concluded that learning to relax and reduce stress may be as effective in reducing headaches as taking medication (Penzien, Rains, and Andrasik, 2002).

Adolescents also respond well to mind-body approaches. Their tension-type headaches responded well to relaxation training; migraine headaches needed therapist-assisted relaxation (Larsson, Varlsson, et al, 2005). A study of headache sufferers using an internet-based headache program consisting of relaxation, autogenic training, and stress management significantly improved and used less medication, even at two-months' follow up (Devineni and Blanchard, 2005). Authors of another review reported that, of all the CAM approaches studied, "only self-hypnosis/guided imagery/relaxation for recurrent pediatric headache qualified as an empirically supported therapy" (Tsao and Zeltzer, 2005).

Guided imagery, especially as an adjunctive treatment, can be a cost-effective way to reduce the frequency, duration, and intensity of headaches, as well as the number of headache-related office visits.

Astin, JA. Mind-body therapies for the management of pain. Clin J Pain. 2004. Jan-Feb;20(1):27-32.

Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract, 2003 Mar-Apr;16(2):131-47.

Andrasik F. Psychologic and behavioral aspects of chronic headache. Neurol Clin, 1990 Nov;8(4):961-76.

Blanchard EB, Andrasik F, Appelbaum KA, Evans DD, Myers P, Barron KD. Three studies of the psychologic changes in chronic headache patients associated with biofeedback and relaxation therapies. Psychosom Med, 1986 Jan-Feb;48(1-2):73-83.

Blanchard EB, Jaccard J, Andrasik F, Guarnieri P, Jurish SE. Reduction in headache patients' medical expenses associated with biofeedback and relaxation treatments. Biofeedback Self Regul, 1985 Mar;10(1):63-8.

Devineni T, Blanchard EB. A randomized controlled trial of an internet-based treatment for chronic headache, Behav Res Ther. 2005 Mar;43(3)277-92.
Ilacqua GE. Migraine headaches: coping efficacy of guided imagery training. Headache. 1994 Feb;34(2):99-102.

Larsson, B, Varisson J, Fichtel A, Melin L. Relaxation treatment of adolescent headache sufferers: results from a school-based replication series. Headache. 2005 June: 45(6)692-704.

Mack KJ, Mack P. Migraine Headache: Pediatric Perspective. 2001.
Accessed July, 2006.

Mannix LK, Chandurkar RS, Rybicki LA, Tusek DL, Solomon GD. Effect of guided imagery on quality of life for patients with chronic tension-type headache. 1999 Headache. May;39(5):326-34.

National Institute of Neurological Disorders and Stroke. Headache — Hope Through Research.
Accessed July, 2006.

Olness K, MacDonald JT, Uden DL. Comparison of self-hypnosis and propranolol in the treatment of juvenile classic migraine. Pediatrics. 1987 Apr;79(4):593-7.

Penzien DB, Rains JC, Andrasik F. Behavioral management of recurrent headache: three decades of experience and empiricism. Applied Psychophysiology and Biofeedback. 2002 Jun; 27 (2): pp 163-81.

Reid GJ, McGrath PJ. Psychological treatments for migraine. Biomed Pharmacother. 1996;50(2):58-63.

Solomon GD, Cady RK, Klapper JA, Ryan RE. Standards of care for treating headache in primary care practice. National Headache Foundation. Cleve Clin J Med. 1997 l64:373-83.

Tsao, JC, Zeltzer, LK. Complementary and Alternative Medicine Approaches for Pediatric Pain: A Review of the State-of-the-science. Evid Based Complement Alternat Med. 2005 June 2(2):149-159.

Zsombok T, Juhasz G, Budavari A, Vitrai J, Bagdy G. Effect of autogenic training on drug consumption in patients with primary headache: an 8-month follow-up study. Headache. 2003 Mar:43(3):251-7.