Underuse of Behavioral Treatments for Headache: a Narrative Review Examining Societal and Cultural Factors

DOI: https://doi.org/10.1007/s11606-020-06539-x

Abstract-Summary As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care.

There is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized.

Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that rec- ommend against them.

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4 Treatment

Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. We review the societal and cultural challenges that impose barriers to optimal

use of non-pharmacological treatment services.

These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment.

He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the

50% reduction in headache days his doctor had hoped for.

His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the chal- lenges in finding an in-network provider proved difficult.

Introduction Research has shown that migraine is under-diagnosed and under-treated in the pri- mary care setting, with close to 40% of people with migraine needing preventive therapy but only 13% of them actually receiving it [583].

Migraine preventive medications do not need to be the main emphasis of migraine

preventive therapy.

Behavioral therapy for migraine (e.g., CBT, biofeedback, and relaxation tech-

niques) also have grade A evidence for migraine prevention.

Research has shown that a clear majority of PCPs are aware that biofeedback is an evidence-based preventive treatment for migraine, whereas knowledge of CBT and relaxation training is much more varied.

Furthermore, even with awareness of the role of behavioral therapies in headache

prevention, there is a demonstrated knowledge-to-implementation gap [584, 585].

Methods The team comprised two board-certified neurologists who are headache experts with research focusing on migraine and behavioral therapy, five psychologists with a special interest in headache, and a psychiatrist who collaboratively worked to determine which resources to use.

This is a narrative, rather than a systematic, review, and we did not formally

define search terms.

Results and Discussion In an assessment of PCPs’ migraine knowledge, one-third of providers were not aware that the American Academy of Neurology’s evidence-based guidelines for preventive non-pharmacologic headache treatment included biofeedback, CBT, and relaxation training [584].

Although the American Headache Society (AHS) disseminates education mate- rials for primary- care professionals, [586] including U.S.  Headache Consortium Guidelines that support inclusion of behavioral strategies in every patient’s treat- ment, [587, 588] a substantial proportion of medical professionals only refer patients with longstanding or complex headache presentations, or poor responders to

4.8 Psycho-Behavioral Interventions

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pharmacological therapies; in reality, behavioral therapies are well-tolerated and cost-effective treatment options for most people with migraine [589].

Recommendations for healthcare providers on how to refer patients for non- pharmacological treatments [590, 591] include emphasizing that behavioral therapy is a first-line option for headache-specific intervention, not treatment for mental illness or reserved for refractory patients with comorbidity, and combined drug and non- pharmacological therapy can produce better outcomes than either modality alone [592]. This change helps providers relay two direct messages to patients: (a) migraine and tension-type headaches are brain diseases, and (b) referral for non-pharmaco- logical treatments is to address behaviors and cognitions that trigger or exacerbate headache, not to find or address mental or emotional problems that may better explain their symptoms [593].

Conclusion Factors such as lack of knowledge regarding non-pharmacological treatment options, demographic-and ethnic- based disparities, stigma toward headache and mental health treatment, and sparse availability of trained clinicians continue to serve as barriers to treatment utilization.

Especially during the opioid epidemic, education aimed at current healthcare practitioners and trainees is imperative, [590] with exposure to non-pharmacologi- cal treatment options during medical training and within clinical practice increasing the probability of changing the culture over time, standardizing patient referral for such treatments.

Finally, models of behavioral treatment must be explored that extend the reach of and accessibility to the still-limited number of clinicians trained in non-pharmaco- logical headache treatment [594, 595].

Research that matches patient factors with the ideal combination of therapist guidance and psychoeducational materials may facilitate adherence to, and ulti- mately utilization of, non-pharmacological interventions.

Acknowledgement A machine generated summary based on the work of Langenbahn, Donna; Matsuzawa, Yuka; Lee, Yuen Shan Christine; Fraser, Felicia; Penzien, Donald B.; Simon, Naomi M; Lipton, Richard B.; Minen, Mia T. 2021 in Journal of General Internal Medicine.

Adherence to Behavioral Therapy for Migraine: Knowledge to Date, Mechanisms for Assessing Adherence, and Methods for Improving Adherence