Barriers to Behavioral Therapy in Headache Management

By Deena Kuruvilla, MD

As a part of my standard treatment approach, I discuss behavioral interventions, mainstream pharmacological treatments and other integrative approaches such as magnesium and riboflavin. More often than not, patients opt for medication approaches and say they will consider behavioral approaches later. They usually tell me the following reasons: “I cannot invest time in behavioral sessions” or “I would rather handle my anxiety myself.” This month’s article by Matsuzawa and colleagues provide useful tools on how to gauge patient beliefs about behavioral therapy in order to provide optimal headache management.

Matsuzawa and colleagues shed light on some important factors which influence patient adherence to behavioral therapy. This article not only highlights the importance of a multi-disciplinary approach to headache management but also provides a patient perspective regarding behavioral approaches. Behavioral therapy has been shown to reduce headache frequency and decrease headache burden in previous studies. More specifically, there is a large body of evidence supporting the efficacy of relaxation therapy, biofeedback, cognitive behavioral therapy and other psychological approaches.

In a 2016 narrative review by Gaul and colleagues in Cephalalgia, the authors state that patients with a psychological burden can especially benefit from multidisciplinary treatment. They go on to specifically recommend the following components to headache management: cognitive behavioral therapy, appropriate drug treatment, patient education, relaxation training and physical therapy.

Back to this month’s feature article by Matsuzawa et al, the authors first differentiate (1) patient compliance and (2) adherence. They state that compliance refers to patients following recommendations from their healthcare provider while adherence refers to what extent a patient’s behavior coincides with medical advice. Their study aimed to provide a narrative review to identify barriers to behavioral therapy in headache management. This article also provides ways how we as physicians can communicate better with our patients and address barriers to behavioral therapy.

Four neuropsychologists conducted literature searches in PubMed, an online research tool, using keywords such as headache, migraine, adherence, compliance, barriers to treatment and other psychological factors. They found that the biggest obstacles to behavioral treatment success were the patient’s attitude and beliefs, patient readiness, lack of knowledge/lack of awareness of triggers, locus of control (LOC), self-efficacy and poor coping skills. LOC is divided into internal and external facets. Internal LOC is the perception that things are under one’s control, while external LOC is the perception that things are out of one’s control and in the control of chance or a healthcare professional’s treatments. The literature favors better treatment outcomes in internal LOC.

The article goes on to provide useful interventions for patients with specific attitudes and belief. Overall they advise us as physicians to assess an individual’s perception of behavioral treatment. It is important to gather the patient’s thoughts about non-pharmacological treatments before providing a referral to a behavioral health provider. By knowing their train of thought, we should be able to provide the patient the appropriate education and encouragement while also managing expectations. Each patient we evaluate on a daily basis is very different based on their comorbidities, personal beliefs and many other factors. Therefore, each patient deserves a customized approach that is in line with their belief system.


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