Headache Disorders: Lifestyle & Behavioral Management

Migraine and Other Headache Disorders Are a Biologic Disorder With Psychologic Factors

It is important to recognize that migraine and other headache disorders are primarily a biologic condition.¹ Psychologic factors, however, can be involved in 4 different ways.

1. Psychologic stressors can trigger attacks,

2. Severe headache disorders can cause significant stress and, in turn, exacerbate frequency and severity attacks,

3. Psychology-based pain management techniques can help people cope more effectively (even when psychologic stress is not a significant cause of headache episodes),

4. There is a demonstrated complex bidirectional association between mood disorders and migraine.⁵

The Role of Nonmedication Management

Nonmedication approaches play a critical role in the management of headache disorders. The same lifestyle choices that promote overall good health can also reduce frequency, severity, and disability associated with migraine and other headache disorders (Table).⁶ Clinicians should explain recommendations for behavioral treatments so that patients understand these treatments are a tool for managing their headache disorder and not a sign that the clinician views the disorder as a psychologic problem.⁵ It is crucial to normalize behavioral strategies as an essential and evidence-based component of treatment, so that patients do not interpret recommended behavioral treatment as a suggestion that headache disorders are psychologic or “in their head.”⁷

Studies have shown that behavioral therapies benefit people with headache disorders (Table), even those without comorbid anxiety and/or depression.^8-17 Anticipatory anxiety is associated with migraine attacks and stress is a common trigger for migraine attacks. Behavioral therapies tend to work on that stress response and reduce cortisol levels and muscle tension, both of which contribute to migraine attacks.¹⁸

Specific Nonmedication Treatments

Headache Diary

Keeping a diary is among the most effective strategies for identifying triggers and can assist in treatment modifications. The diary should at least include frequency, duration, intensity, analgesic use, and effect on function and absenteeism. Potential triggers, including menses, should also be tracked.¹⁹

Environmental Awareness

Counsel patients to stop and think when a migraine attack begins, considering where they are and where they can go. Removing oneself from usual activities and any triggers, and when possible finding a quiet room where the lights can be dimmed or turned off can be very beneficial. Hot or cold compresses applied to the head or neck can help dull the pain, and warm showers or baths may have a similar effect. Heat can help ease tense muscles and may also be relaxing. Inhaling peppermint is effective in relieving headache severity for some.²⁰

Eating Habits

Eating around the same time every day without skipping meals reduces migraine attack frequency. There is no benefit, however, to discontinuing foods indiscriminately because triggers vary from individual to individual (my triggers may not be your triggers), except for caffeine.²¹ If used infrequently, small amounts of caffeine can treat an attack, but frequent caffeine use can lead to caffeine withdrawal headache and possible transformation of episodic into chronic migraine. Excessive caffeine late at night can also disrupt sleep, which can affect migraine. Staying hydrated by drinking 7 to 8 glasses (8 oz) of water a day can reduce migraine attack frequency.²⁰ A diary is indispensable to keeping track any associations between attacks and specific eating and drinking patterns or foods.

Eliminate Headache-Causing Medications

Many medications list headache as a side effect, including nitrates, caffeine-containing compounds, oral contraceptives (although these may be helpful for menstrual migraine) hormone replacement therapy, and certain medications for coronary artery disease and high blood pressure. Many other drugs cause headache, and it is important to review the side effects of all medications during assessment and treatment of headache disorders and whenever a new prescription is given.

Exercise

Exercising for 30 to 60 minutes 3 to 5 times a week is recommended.¹⁹ During physical activity, endorphin release may help alleviate anxiety and depression, which can both worsen migraine.^22,23 Obesity also increases risk of chronification, so maintaining a healthy weight can provide additional benefits in managing migraine. A body mass index of 18.5 to 25 kg/ m² is a good goal.¹⁹ Encourage people to choose forms of exercise they like to make it a lifestyle change. For those who have not been exercising regularly, it is important to ease into a program of exercise because vigorous exercise may trigger migraine attacks in people accustomed to being sedentary.

Sleep Hygiene

Too much or too little sleep can exacerbate migraine, making good sleep hygiene a fundamental need for people with migraine (Box 1).^1,19 Behavioral modifications for sleep hygiene can convert chronic migraine to episodic migraine. Stimulus control therapy focuses on using cues to initiate sleep period patience and courage to keep the bedroom quiet, dark, and cool and to go to sleep at the same time every night. Importantly, the bed should be associated only with sleep or intimacy. If someone is not able to fall asleep within 20 to 30 minutes, they should leave the bedroom to avoid associating their bed with frustration and anxiety. Use of phones, tablets, and television in the bedroom is discouraged because these devices may make it more difficult to fall asleep.¹⁹ Snoring is associated with early morning migraine attacks and should prompt an evaluation for sleep apnea.

Stress Reduction and Muscle Relaxation

For most people, stress reduction is far easier to say than to do, but that does not mean stress reduction techniques do not have value. Biofeedback and relaxation techniques such as mindfulness and visualization or progressive muscle relaxation are very effective. A great resource for relaxation techniques can be found at www.dawnbuce.com. Self-hypnosis, yoga, tai chi, and cognitive-behavioral therapy (CBT) are also very effective techniques for stress reduction shown to have effects on reducing frequency and severity (Box 2).

Muscle Relaxation

Nocturnal bruxism and pain of the muscles around the lower jaw muscles are associated with migraine. Worn teeth, aching jaws or “pops” and “clicks” on jaw movmeent should prompt evaluation for temporomandibular joint syndrome.

Conclusion

Headache disorders, including migraine, are very common with myriad etiologies. Behavioral and lifestyle change or modification is proven to be effective for various headache types by, sometimes uncovering and treating a root cause of migraine, for example, and often relieving associated suffering and disability. Incorporating aspects of this broad treatment category with other treatment strategies is highly recommended to increase the likelihood of successful treatment outcomes.