Combined Pharmacologic and Behavioral Approach May Improve Migraine Management

LAS VEGAS — Although there is growing recognition of the critical role that psychological factors play in both the development and maintanence of pain, many physicians continue to base treatment solely on a biomedical model instead of a biopsychosocial one. This may be due to lack of awareness of the importance and efficacy of biobehavioral approaches, suggests a needs assessment and call to action that was recently published in Pain Medicine.¹ A presentation at PAINWeek 2016 helped to address that information gap, with a special focus on migraine management.²

Dawn C. Buse, PhD, director of behavioral medicine at the Montefiore Headache Center, touched on research that demonstrated that combined pharmacologic and behavioral treatment approaches are more beneficial than either approach alone for chronic pain conditions including migraine, and that patients who demonstrated improvement following an interdisciplinary pain program had sustained responses.³

“There are many of benefits of behavioral interventions for migraine management. They are inexpensive and cost-effective, they can be practiced alone or in conjunction with pharmacotherapy with no side effects. In addition, they are self-care based activities that can enhance self-efficacy and encourage active participation in disease management,” Dr Buse told the audience during her presentation.

The relaxation response, which Dr Buse called a core element of “many of the empirically validated biobehavioral therapies,” involves shifting the balance from the sympathetic branch of the autonomic nervous system to the parasympathetic branch. The “fight-or-flight” response can influence the perception and experience of pain. There are several empirically validated approaches that can elicit the relaxation response, including various breathing and relaxation techniques and progressive muscle relaxation (PMR), which involves contracting and relaxing each muscle group to learn how to recognize and relieve tension. A 2013 study concluded that a combination of these techniques led to reduced duration, frequency, and severity of headaches, as well as headache-related disability in young adults.⁴ Participants also showed reductions in depression and anxiety.

Psychological treatment approaches for pain management include cognitive behavioral therapy (CBT) with stress management training, biofeedback, and relaxation training among others. These involve, to varying degrees, changing dysfunctional thought patterns that can influence emotion, perception, and behavior, thereby altering the pain experience. Additionally, biofeedback has demonstrated high efficacy for pain disorders, including tension-type and migraine headaches.⁵ It teaches patients to alter their autonomic response through instant feedback regarding their physical state. 

Referral to a behavioral specialist is required for biofeedback and CBT, but not for all biobehavioral treatment approaches. Dr Buse discussed when referral is appropriate and how to approach the referral topic with patients. Providers should assure patients that their condition is biological and not “all in their head,” she explained.  She also advised reassuring patients that they are not being passed off to a mental health specialist, but rather that person is joining the treatment team.

Biobehavioral treatments are “clinically effective, cost-effective and do not carry the potential for side effects or interactions,” Dr Buse noted. “The are ideal for women who are pregnant, lactating, or may be trying to conceive. For optimal migraine management, a combination of pharmacological and nonpharmacological approaches has been demonstrated to be superior to either approach on its own,” she said. 

Dr Buse directed meeting participants to numerous relaxation exercises and referral resources available at her website: dawnbuse.com. For more on some of the relaxation techniques, watch the video below. 

References

1. Darnall BD, Scheman J, Davin S, et al. Pain Psychology: A global needs assessment and national call to action. Pain Med. 2016;17(2):250-263.
2. Buse D. Biobehavioral management of migraine. Presented at: Pain Week 2016. Las Vegas, NV; September 6-10, 2016.
3. Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain. 1992;49(2):221-230.
4. Slavin-Spenny O, Lumley MA, Thakur ER, Nevedal DC, Hijazi AM. Effects of anger awareness and expression training versus relaxation training on headaches: a randomized trial. Ann Behav Med. 2013;46(2):181-192.
5. Nestoriuc Y, Martin A, Rief W, Andrasik F. Biofeedback treatment for headache disorders: a comprehensive efficacy review. Appl Psychophysiol Biofeedback. 2008;33(3):125-140.

This article originally appeared on Clinical Pain Advisor