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SCOTTSDALE, Ariz. -- Behavioral treatment can improve headache and migraine outcomes significantly, a researcher said here.

Behavioral therapy can help headache patients develop self-efficacy -- "the belief in their ability to control their headache, manage their emotional reactivity to pain, and achieve functionality even with a significant headache disorder," said Steven Baskin, PhD, of the New England Institute for Neurology and Headache in Stamford, Connecticut, at the American Headache Society Scottsdale Headache Symposium.

Stress, anxiety, and depression play significant roles in migraine, Baskin said in a plenary session. "High levels of daily stress, even daily stressors that are not catastrophic, can transform migraine from episodic to chronic," he pointed out. "Let-down" post-stress -- the period after a particularly stressful situation -- may precipitate a migraine, and the effect may be greater in migraine patients with comorbid depression.

"Many patients do not have the coping skills necessary to manage stress or recurrent headache," Baskin said, and behavioral therapy can give patients tools and confidence to manage headaches and stressors.

This is especially true for patients who are anxious or depressed, he added. Anxiety may complicate migraine more than depression with greater long-term persistence, greater headache-related disability, and reduced satisfaction with acute therapies. And nonadherence to treatment regimens can be three times more likely when patients have mood or anxiety disorders. These patients also may be less able to tolerate medications or may have response to pharmacologic and behavioral treatments for headache.

Depending on the specific patient, behavioral therapy could include headache diaries, regulating routine activities, establishing consistent sleep patterns, relaxation training, biofeedback, coping skills training, cognitive behavioral therapy (CBT), and psychiatric treatment. Clinicians don't necessarily need to refer patients to a therapist to help them modify their behavior.

"Encouraging patients to reduce caffeine, maintain consistent sleep/wake patterns, eat nutritious meals, and increase aerobic exercise is incredibly helpful," Baskin said.

Teaching relaxation techniques works well, too. "Instructing patients about simple relaxation therapy is a core component of behavioral treatment for primary headache disorders," he noted. "Simple breathing exercises can be done right in your office without any referral. Just tell people to breathe slower, and lower, and do it frequently during the day."

Relaxation therapy can be delivered alone, or as part of biofeedback or CBT. "What biofeedback does is make patients realize that they have more control over their internal environment," Baskin pointed out. "They learn a non-specific, low-arousal physiological response they can apply and use as a coping skill: if you have a prodrome aura, you can stop, take a slow easy breath, and make an action plan."

CBT helps patients modify their sense of threat about migraine and examine their negative predictions. "I have patients actually rehearse what they are going to do if they start to develop a migraine," he added.

The 2000 American Academy of Neurology guidelines for behavioral treatments for migraine for relaxation training, some types of biofeedback, and CBT as grade A. More recent research demonstrated that combining a -- but not a beta-blocker alone or behavioral treatment alone -- improved outcomes of optimized acute migraine treatment.

A 2018 meta-analysis also showed that of insomnia for chronic migraine patients reduced their monthly headache frequency by 6.2 days over controls.

"A physician should refer a patient to behavioral therapy if the patient prefers non-pharmacological therapy; if the patient is a poor responder or has poor tolerance to preventive meds; is pregnant; has high anxiety or high stress level or deficient coping skills; has history of excessive use of abortive agents; or to augment pharmacological therapies," Baskin told MedPage Today.

Behavioral therapy also should be considered for all children and adolescents, he added.