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

Abstract

Migraine affects over 40 million Americans and is the world’s second most disabling condition. 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. Though 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 recommend against them. 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. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for 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. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization. Case Example A 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. 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 challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.

Essential components of care in a multidisciplinary headache center: Perspectives from headache neurology specialists

“…Multiple knowledge, access, and societal barriers prevent appropriate physician referral for, and patient uptake of, behavioral treatments for headache. [31][32][33] Steiner et al offer ten standards and criteria for quality in headache centers, noting that headache care should be tiered from primary care, to care from physicians with special interests in headache, with specialty headache centers as tertiary referral centers for only the most difficult-to-treat patients. 7 Given the scarcity of UCNScertified headache specialists and specialty headache resources within individual headache centers and across the US, 15,34 it is worth considering whether ongoing management in headache centers of all patients who have been referred to the centers constitutes the most effective use of resources.…”

Behavioral Health, Telemedicine, and Opportunities for Improving Access

“…Societal and cultural concepts related to seeking psychological care may also interfere with seeking in-person behavioral care for chronic pain and headache disorders [ 45 ]. For example, patients may believe that a referral to a psychologist indicates their medical provider does not believe their pain is “real,” or that a referral to a pain psychologist is for a mental health concern rather than pain management.…”

Digital headache self‐management interventions for patients with a primary headache disorder: A systematic review of randomized controlled trials

“…4,5 To target all aspects of headache (frequency, duration, severity, and disability), effective treatment requires a multimodal approach including pharmacological therapy, biobehavioral interventions, and adherence to healthy lifestyle habits. [6][7][8][9] Although in-person behavioral interventions improve treatment adherence, disease management, and health outcomes among patients with headache and migraine, [10][11][12] these services are typically only available in multidisciplinary tertiary care settings, [13][14][15] whereas at least two thirds of primary headache and migraine concerns are seen in primary care settings. 14,16,17 Additionally, many patients encounter barriers accessing treatment services as well as effectively translating skills learned in clinic into their daily routines across various environmental settings (e.g., home, work, and school).…”