Efficacy and Feasibility of Behavioral Treatments for Migraine, Headache, and Pain in the Acute Care Setting

DOI: https://doi.org/10.1007/s11916-020-00899-z

Abstract-Summary This narrative review examines the use of behavioral interventions for acute treat- ment of headache and pain in the emergency department (ED)/urgent care (UC) and inpatient settings.

Behavioral interventions demonstrate reductions of pain and associated disabil-

ity in headache, migraine, and other conditions in the outpatient setting.

Behavioral treatments may be a useful addition for patients presenting with acute

pain to hospitals and emergency departments.

There are few high-quality studies on behavioral treatments in the inpatient and

emergency department settings.

Introduction Acute pain, headache, and migraine are common reasons for presentations to emer- gency departments and for admissions to the hospital [607].

Behavioral interventions are not a standard part of inpatient or emergency depart-

ment (ED)/urgent care (UC) for migraine, headache, or pain treatment [608].

The safety and efficacy of many behavioral treatments for pain and headache has

been demonstrated convincingly in the outpatient setting [609].

This review discusses the application of behavioral treatments for treating acute

inpatient pain.

Given these physiologic differences, there may be different levels of effective-

ness of behavioral interventions for acute pain compared with chronic pain.

We will review the evidence base of these interventions for acute pain, migraine,

and headache.

Evidence Base in the Outpatient Setting Relaxation training, biofeedback, and cognitive behavioral therapy have strong evi- dence of effectiveness for migraine and tension-type headache management [610]. Haddock et  al. [611] analyzed 20 trials of home-based behavioral treatments (including home-based relaxation treatments, biofeedback, and minimal therapist contact CBT) and found them equally effective, or superior to, clinic-based interventions.

Holroyd et. al. [612] performed a trial of 203 adults with chronic tension-type headache randomly assigned amitriptyline or nortriptyline vs. placebo vs. stress management therapy (relaxation and cognitive coping strategies taught over 3 face- to-face sessions and 2 telephone contacts) and found that pharmacotherapy was equally effective compared with behavioral therapy.

To the above well-established behavioral therapies for migraine, acceptance and commitment therapy (ACT), mindfulness- based interventions (MBCT and MBSR), and sleep interventions are emerging as potentially effective migraine treatments, but more data is needed before these can be definitively recommended [613].

4.8 Psycho-Behavioral Interventions

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Evidence Base for Behavioral Treatments for Pain and Primary Headache in the Experimental and Acute Settings Petter [614] randomized 198 adolescents to a mindful attention manipulation or control group prior to an experimental pain task (the cold pressor task, in which the subject places their hand in cold water and time submerged is measured).

The authors found no effect on pain, but interestingly, regular meditators in the mindful attention group reported lower pain intensity than mediators in the control condition (mean pain score on a 10-point scale were 5 and 6.5, p < 0.5).

Garland et al. [615] ran a randomized-controlled trial of mindfulness for inpa- tient pain comparing mindfulness training vs. hypnotic suggestion vs. psychoeduca- tion for acute pain relief in the hospital setting.

The authors found that the single brief mindfulness or hypnotic suggestion inter-

vention reduced pain more than the psychoeducation group.

The authors found significantly reduced pain intensity in the hypnosis group compared with the massage group while the patients were hospitalized (p = 0.008).

Discussion Despite the evidence base for many behavioral treatments delivered or taught in the outpatient setting, more robust studies in the inpatient setting are needed before they become a routine part of inpatient pain treatment.

Control groups can be no treatment (e.g., a waiting list control), minimal treat- ment (e.g., a very brief intervention), a non- specific active control (a condition in which no clear rationale for the treatment is provided), or a specific active con- trols (a condition where a clear rationale for the treatment is provided to the patient).

Ernst et  al. [591] classified barriers to behavioral treatment for migraine into

patient and provider-related.

These treatments require patient buy-in and will not work for patients uninter- ested in these treatments [610] or patients in too much pain to focus on the interventions.

It may be possible to take a patient into a less stimulating treatment room of the

ED to teach a behavioral intervention.

Conclusion There have been numerous studies on behavioral treatments for acute experimen- tally induced pain, with evidence for mindfulness- based therapies, relaxation, and hypnosis treatments.

There is a much smaller body of literature for the application of behavioral treat- ments to the management of headache, migraine, and pain in acute inpatient or emergency department or urgent care settings.

Some research supports the acute use of relaxation therapies, mindfulness-based

therapies, hypnosis, and virtual reality- based delivery systems in these settings.

Acknowledgement A machine generated summary based on the work of Vekhter, Daniel; Robbins, Matthew S.; Minen, Mia; Buse, Dawn C. 2020  in Current Pain and Headache Reports.

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4 Treatment

ACT for migraine: effect of acceptance and commitment therapy (ACT) for high-frequency episodic migraine without aura: preliminary data of a phase-II, multicentric, randomized, open-label study