Behavioral and Mind/Body Interventions in Headache: Unanswered Questions and Future Research Directions

Abstract

Background.-Many unanswered questions remain regarding behavioral and mind/body interventions in the treatment of primary headache disorders in adults.Methods.-We reviewed the literature to ascertain the most pressing unanswered research questions regarding behavioral and mind/body interventions for headache.Results.-We identify the most pressing unanswered research questions in this field, describe ideal and practical ways to address these questions, and outline steps needed to facilitate these research efforts. We discuss proposed mechanisms of action of behavioral and mind/body interventions and outline goals for future research in this field.Conclusions.-Although challenges arise from the complex nature of the interventions under study, research that adheres to published study design and reporting standards and focuses closely on answering key questions is most likely to lead to progress in achieving these goals. Key words: alternative medicine, headache, mind/body Abbreviations: CAM complementary and alternative medicine, TTH tension-type headacheNon-pharmacological interventions have long been perceived by patients and providers as beneficial for headaches, and strong evidence supports the useful effects of certain nonpharmacological interventions for migraine and tension-type headache (TTH). The US Headache Consortium Guidelines for prevention of migraine identified Grade A evidence to support several specific non-pharmacological interventions including relaxation training, thermal biofeedback combined with relaxation training, electromyographic (EMG) biofeedback, and cognitive behavioral therapy (CBT) 1 (labeled as "evidence-based behavioral interventions" for this paper). The combination of preventive drug therapy and evidence-based behavioral therapies was identified as having Grade B evidence for producing added clinical benefit, although data published since these guidelines were issued is likely to change the evidence to Grade A when the guidelines are updated. 2,3 In addition to evidence-based behavioral interventions, a recent study found that more than 50% of US adults with migraines/severe headaches reported having used complementary and alternative medicine (CAM) techniques, most commonly "mind/body therapies" such as meditation and yoga. 4 Thus, although data most strongly support evidence-based behavioral interventions, it seems that mind/body interventions are used frequently by adults with primary headache disorders. Despite their use, many unanswered questions remain regarding these non-pharmacological interventions in the treatment of primary headache disorders in adults. In 2005, Headache published an entire series of peer-reviewed papers (many cited in this review) that provided in-depth analysis of numerous methodological issues and suggested solutions in behavioral headache research. Given the increased utilization of mind/body therapies and potentially similar underlying mechanisms between evidencebased behavioral interventions and mind/body therapies, the goal of this paper is to id...

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