Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy.

Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management.In this article we describe the mood and anxiety disorders most commonly associated with migraine, tensiontype headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.

Assuming control over the allocation of patients to treatment conditions is a fundamental element of any comparative clinical trial. There are three critical considerations investigators must balance in choosing an allocation scheme: reducing bias in patient allocation, producing balanced patient groups across treatment arms, and reducing the likelihood of errors attributable to chance variation. The authors review the principles of three key approaches to the allocation of patients to conditions within clinical trials, and their respective advantages with regard to these critical considerations. These allocation methods include randomization, stratification, and patient-treatment matching. Randomization is fundamental to most clinical trials. Stratification is an advanced step in a systematic program of research investigating the efficacy and effectiveness of an intervention. If the trial has less than 100 per arm and there is a known prognostic factor, stratification is the best choice to ensure equal allocation across groups. Treatment matching (tailoring) attempts to match the most appropriate treatment to a specific patient based on a priori hypotheses. Two techniques used for exploring treatment matching are: patient typologies (patient profiling), and aptitude-treatment interactions. Additional details pertaining to the rationale for selecting among these various approaches to patient allocation is provided, and their methodology is summarized with specific consideration for their application within clinical trials of headache treatment.

This article evaluated the ability of propranolol to enhance results achieved with relaxation-biofeedback training. Thirty-three patients were randomized to relaxation-biofeedback training alone (administered in a limited-contact treatment format), or to relaxation-biofeedback training accompanied by long-acting propranolol (with dosage individualized at 60, 120, or 180 mg/day). Concomitant propranolol therapy significantly enhanced the effectiveness of relaxation-biofeedback training when either daily headache recordings (79% vs. 54% reduction in migraine activity) or neurologist clinical evaluations (90% vs. 66% reduction) were used to assess treatment outcome. Concomitant propranolol therapy also yielded larger reductions in analgesic medication use and greater improvements of quality of life measures than relaxation-biofeedback training alone but was more frequently associated with side effects.

Chronic daily headache is a heterogeneous group of daily or near-daily headaches that afflicts close to 5% of the general population and accounts for close to 35% to 40% of patients at headache centers. First-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of headaches. However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. Cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, improving headache-related disability, affective distress, and quality of life, and reducing overreliance on medication. For cognitive-behavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance.