Both migraine and muscle tension headache have long been thought to be triggered by psychological factors. There is reasonable, but not overwhelming, evidence to support this notion.1,2 The logic of using psychological or behavioral treatments is derived from this unproven observation. However, a treatment may be effective even if it is not directly related to the cause of a disorder. The effectiveness of psychological treatments for headaches does not prove that such headaches are of psychological origin, nor is it necessary for a headache to be of psychological origin for it to be modified by psychological interventions.
Many well-designed trials of behavioral treatments for headache have demonstrated effectiveness.3'9 Behavioral treatments are better validated in children and adolescents than prophylactic medical treatments such as propranolol10 or sumatriptan. If behavioral treatments are available, they are the treatment of choice for significant headache that does not respond adequately to simple analgesics.
ALTERN ATIVES AVAILABLE TO THE PRIMARY CARE PHYSICIAN
The primary care physician faced with a child or adolescent with tension or migraine headache has a series of options. In some cases, reassurance that there is no significant medical problem (such as a brain tumor) and the directive to use acetaminophen or Ibuprofen appropriately will be sufficient. The importance of these initial, cost-effective strategies should not be minimized. If headache is seen as a signal of a serious problem by the family or by the child, the occurrence of a headache, even a minor headache, will trigger a response that is likely to exaggerate pain and enhance disability and handicap. Negative attitudes toward over-the-counter medication are common (eg, children may learn to use drugs to solve other problems, using medications is like giving in to pain, medication use may lead to drug abuse, and medications have adverse side effects) and may easily contribute to inadequate medication. If over-thecounter medication is taken in inadequate doses or only when the headache has become well established, headaches are likely to be more severe and debilitating. Thus, parents and children should be encouraged to take medications in sufficient dosage at the first sign of an impending headache. Discussion of parents' views on such treatment also is warranted to identify and correct misconceptions about medication use.
If there are significant family problems, referral to a mental health professional may be appropriate. Psychotherapists and family therapists of all persuasions treat child and adolescent patients who have headache; in some cases, therapy is effective in reducing headache. If conflict within the family is a primary source of stress for the child, reducing the intensity of this stressor may have positive effects on the child's headaches. However, the effectiveness of psychotherapy and family therapy, as a headache treatment, has not been validated by scientific trials. In addition, family therapy and psychotherapy are expensive, psychologically invasive, and may not be acceptable to some families. Alternatively, a referral can be made to a psychologist (or other therapist) who is particularly skilled in behavioral treatments aimed at improving the coping skills and stress management techniques of the child.
PRIMARY CARE TREATMENT OF HEADACHE
For many patients, a more useful approach than routinely prescribing psychotherapy, family therapy, or behavioral therapy for pediatric and adolescent headache is for the primary care physician to: 1) systematically examine potential problems that may be causing stress triggering headaches and to attempt to resolve these problems and 2) use simple behavioral treatments to help the patient reduce the frequency and intensity of pain. There are no scientific trials on this strategy, but it is likely to be helpful in a sizable proportion of patients. This approach requires that the physician be able to build rapport with the afflicted child or adolescent and with the parent. It also requires scheduling of somewhat longer appointments than is typical in primary care. It is likely that at least one or two more lengthy discussions of the patients situation will be required. These cannot be done in 5 minutes and likely require scheduled appointments of 20 to 30 minutes.
Identifying and Reducing Stressors
Consultation with both parents is often helpful to determine sources of stress and to enlist the parents in taking a consistent approach to help their child. The child or adolescent should be seen individually to elicit sources of stress. The child's teacher(s) should be contacted, usually by telephone or perhaps by a letter or questionnaire, to find out how the child is coping with school.
The most common sources of stress for children and adolescents are: marital or family conflict; rejection or harassment by peers at school, on the school bus, or on the playground; depression; anxiety; sleep disturbance; and learning problems. Sexual and physical abuse are less common sources of stresses that also should be probed.
It is useful to have the child (or the parents) keep a log or diary of headache, stressors, medication, and coping strategies (thoughts and behaviors). With children younger than 6 or 7 years, the diary is kept primarily by a parent. With children 7 to 10 years, the diary is kept jointly by the child and the parent, and with children 1 1 years and over, the diary is best kept by the child alone. The diary serves as a way for die child to understand and take control of his or her headaches. The Figure is an example of a headache diary. In some cases, remediation of headaches is relatively easy and can be accomplished with one or two half-hour sessions. Even if all significant sources of stress have not been resolved, subsequent use of behavioral treatments likely will be helpful.
Behavioral methods include a broad range of techniques. The most commonly investigated behavioral treatments for recurrent headache are relaxation and finger temperature biofeedback, or the two in combination. Cognitive therapy or stress coping has been examined in several trials. These methods can be readily adapted to the primary care situation. Hypnosis is a somewhat controversial method that some physicians and some patients will find quite acceptable. Other forms of biofeedback, such as electromyographic (EMG) biofeedback11 and cephalic artery biofeedback,12 have received less attention as treatments for headache in children and adolescents and also require equipment that is not readily available in primary care. Massage has not been studied widely in headache but can offer relief for some patients. Operant methods involving extinction of pain behavior through selective ignoring and reinforcement of active, healthy behavior have been used widely in the treatment of chronic adult pain patients, many of whom may suffer from headache. However, operant strategies have not often been studied in recurrent headache in children and adolescents.
Figure. Sample headache diary. (1Pain intensity: on a scale of 0 to 10, with 0 being no pain and 10 being worst pain.
Relaxation. Relaxation includes progressive muscle relaxation modelled after Jacobson,13 imagery-based relaxation such as that originally described by Schultz and Luthe,14 and relaxation by way of breathing exercises.15 Cautela and Groden16 have developed exercises specifically for children. Hybridized forms of relaxation often are used, and there is little evidence that the efficacy differs between the procedures. However, combining relaxation with biofeedback or cognitive therapy may result in greater efficacy.11,17
Abbreviated relaxation training can be taught initially in a 10- to 15-minute session in which the child is told the treatment rationale and provided with instruction in relaxation techniques. In subsequent sessions, different body areas can be added and relaxation with tension can be used. For example, after conducting the first session outlined below, session two might focus on these same muscle groups but alternate 2- to 3-second contractions with 4- to 5-second periods of relaxation, repeating twice per muscle group. Tension-relaxation exercises should be continued for muscles in the lower body (ie, buttocks, quadriceps, calves, and feet).
The following is an example of a first session of relaxation training instructions should be modified depending on the cognitive level and circumstances of the child):
Rationale: Headaches are caused by many differenr things. Tension is one thing that often causes headaches. Learning to relax will let you control your body and can help you prevent tension from triggering your headaches.
Instructions: Show the child how to relax in a chair by settling in and closing one's eyes. Demonstrate three deep breaths, inhaling through the nose and exhaling through the mouth, and show visible relaxation from deep breathing. Then invite the child to try it. Make sure the child is comfortable and that his or her head is supported by the chair.
The following instructions can be given slowly while the child follows the directions. Reassure the child that he or she will be in complete control.
"Sit and gently close your eyes. Now pay attention to your breathing. Breathe out a large breath through your mouth. Good, now slowly take in a large breath through your nose. That's right. Hold that for a few seconds and then breathe out slowly. Breathe out all your tension. Now breathe in relaxation. Relax, relax, relax. Relax your face, shoulders, and arms. Relax your face and especially your jaw and forehead. Just let your jaw drop limp and loose. Imagine your shoulders and arms becoming heavier and more relaxed, more calm, more peaceful. Allow your body to sink into the chair. Good. Now breathe slowly and deeply, each time breathing in relaxation and breathing out tension."
Allow the child to breathe in and out about 5 to 10 times more, giving encouragement every couple of breaths. The child then should be asked to try it on his or her own in the office while being observed. Then the child is given the firm instruction to do this three times a day until the follow-up appointment in 7 to 10 days. The timing of the relaxation instruction should be discussed and agreed on. Tying relaxation to an event such as meals is often helpful. The child will have to find a quiet place to do the relaxation. All these details should he worked out before the end of the appointment.
Temperature Biofeedback. Children and adolescents are usually sophisticated about technology and they respond well to biofeedback. In fingertemperature warming or thermal biofeedback, patients learn to wann their hands via feedback of changes in their finger temperature as measured by a temperature strip or a simple thermometer attached to the finger with tape. Practice with temperature biofeedback should be used in conjunction with general relaxation training. The child should be coached to use suggestions of warmth, calmness, and relaxation to try and warm his or her hands. In addition, trial and error is used to learn what other strategies will warm the hands (eg, imagining self in the sun on a beach). The skill is first learned in the office and then consolidated by practice outside of the session. The child is given the small feedback instrument for home use. Eventually, the child should be encouraged to learn to change finger temperature without the aid of the biofeedback instrument and to use this strategy during everyday activities.
Common wisdom dictates that finger temperature biofeedback is used with migraine headache and muscle biofeedback is used with tension-type headache. Most, but not all, children and adolescents with clinically relevant headaches that are not controlled by analgesics have both types of headaches. In addition, there are no convincing data about the specificity of the effects of different types of biofeedback. It is likely that regardless of headache type, most children and adolescents could benefit from temperature biofeedback.
Cognitive Therapy or Stress Coping, Cognitive therapy, also called stress coping or stress management, includes: identification of stressors and reaction to stress, changing thoughts and images about stressful situations, and learning coping strategies to manage stress, including the stress of a headache. These methods are derived from the pioneering work of Beck18 in depression and Meichenbaum19 in selfinstruction. With adolescents, cognitive therapy appears to be as effective as relaxation.9 Simple cognitive strategies can be taught to the average 8 or 9 year old. It does, however, take some time and effort for the child to apply these techniques to day-to-day events.
The first step in using cognitive techniques is the recognition of negative thoughts in response to stressors. The headache diary, described above, is invaluable in this process. By reviewing the diary with the child (and the parents when appropriate), negative thoughts that the child has can be identified. Commonly occurring types of negative thoughts include: catastrophizing about extremely unlikely events (eg, "This pain will never end), ruminating (eg, "I can't stop thinking about how much it hurts"), exaggerating (eg, "I just know he hates me"), externalizing blame (eg, "No wonder I failed, that stupid teacher made the test too hard"), and internalizing or worrying (eg, "It's all my fault").
The second step is the evaluation of how helpful or relevant the child's thoughts or self-statements were in dealing with particular stressors. Lead the child to challenge the validity of his or her negative selfstatements (eg, "When you have had a headache, did it really never go away?"). Other questions may be directed at identifying cause-effect relations between thoughts and stress (eg, "When you say that to yourself, does it make you feel better or worse?").
The third step is substitution of more adaptive cognitions for negative thoughts. Teach the child a variety of alternative cognitions that he or she can use selectively, depending on the stressor. These may include positive self-statements (eg, "I can handle this," "Tilings will be okay," and "It will be over soon") or distraction (ie, thinking about other activities or just not thinking about it).
Finally, children should be instructed on how to self-reward or congratulate themselves when they use a new way of thinking. Statements such as, "Great! I'm getting the hang of uSis," or "I did a good job handling that problem," not only serve to reinforce new ways of thinking but they also help maintain a more positive mood in the face of stress. It is particularly important to have children reward attempts at coping and not just successes. Changing thought processes is hard work and takes time.
After working through the above steps with a number of specific stressors, it is often useful to assist the child in formulating individual stressors into categories. For example, if a child reported the following stressors - being teased by a friend, punched by a sibling, and grounded by parents - he or she could be led to identify interpersonal conflicts as a category of events that trigger headache. This knowledge then may be used to assist the child in applying the steps listed above either preventively or while he or she is experiencing a stressful event.
Hypnosis. Hypnosis is an effective treatment for headache in children.20·21 Hypnosis combines relaxation, imagery, and suggestion to achieve an altered state characterized by deep relaxation and decreased critical cognition functioning. Hypnosis may be induced using a variety of means such as hand lévitation, eye closure, or guided imagery.
Pain relief may be obtained as a result of deep relaxation or posthypnotic suggestions. After successfully experiencing hypnosis in the office, children may be instructed in self-hypnotic techniques. In a primary care setting, sel£hypnosis may be a preferred form of treatment as it allows the child a greater sense of control and teaches a skill that can be used to achieve pain relief between visits.
There are a few limitations or concerns related to hypnosis. First, although the préadolescent age is one in which individuals are the most readily hypnotized, not all children readily experience hypnosis. For these children, relaxation alone probably would be just as effective. Second, hypnosis is a clinical skill that requires advanced training. Finally, parents may react negatively to the term itself. Although use of an alternative name such as relaxation-mental imagery may serve to minimize parental worry, we feel that this term should be used only if this is actually what will be done with the child. If hypnosis (te, induction, imagery, and suggestions of pain relief) is to be the actual treatment, parents and children should be fully informed and have the opportunity to address any concerns before treatment proceeds.
Massage and Posture. Inappropriate posture contributes to headache in adults.22 Forward head posture in which the head is held forward of the spine is the most commonly implicated postural habit. Forward head posture of 15° or greater is generally considered abnormal.22 Forward shoulder posture also may contribute to headache. These positions may occur together, put considerable, constant strain on the cervical musculature, and may initiate tension-type headaches or trigger the cascade of events leading to migraine headache. The role of posture in headache in children is not clear. Although there are no clear data, examination of the posture of children with headache and suggesting that they try to reduce forward head posture is unlikely to be harmful. Changes in posture may be helpful.
Massaging tense muscles can be very relaxing and comforting for a child with headache. If it breaks a pattern of physical tension, then it may prevent the occurrence of headaches. Massage can be as simple as self-massage of the trapezius with the contralateral hand. Alternatively, massage can be conducted by a parent. For the amateur, the best guide for massage, is "Cause no pain."
Operant Techniques. Operant techniques consist of nonreinforcement or punishment for pain behavior and reinforcement for healthy, nonpain behaviors. For example, the primary care physician could instruct parents to ignore their child when he or she complains of headache and attend to the child when the complaints cease and normal activities resume. Effectiveness of such procedures can be maximized by teaching parents how to ignore without becoming upset (eg, walk away and telling themselves they are doing what is best for their child). Modelling for the parent how to use calm, clear instructions so that the child clearly understands the contingencies is also important (eg, "I know you have a headache. When you stop complaining, we can do something you like.").
Parents should be cautioned that children often increase the level of their complaints in response to ignoring. If contingencies are not explained and reinforcement of nonpain behavior is not used, some children may interpret lack of attention to complaints as an indication of their own unworthtness or of parental neglect. Some children may suffer in silence and not obtain the help they need. Thus, prompt, appropriate response by a parent to a child's complaints of headache, combined with careful use of selective attention for nonproductive complaining, can help teach children and adolescents to manage their headaches better.
THE ROLE OF PARENTS
Parents can be encouraged to prompt the use of relaxation, biofeedback, and cognitive strategies. Parents also can prompt posture and give massage. It is critically important that parents use much more positive than negative feedback. Whether feedback is positive or negative depends on the perception of the child, not the intent of the adult. Negative feedback will cause stress for the child and set the stage for an adversarial relationship about the headache problem. Professionals must make careful judgements about how much to involve parents in the treatment of their children.
Children or adolescents who are depressed (even those who are depressed because of their headaches) may have difficulty participating in behavioral treatments. Treatment of the depression may be required prior to headache treatment.
There are very few negative side effects to behavioral treatments. The specific dangers of operant treatments have been discussed. In addition, some individuals who are susceptible to panic attacks may find it difficult to engage in relaxation training or biofeedback without triggering a panic attack.
Providing behavioral treatments within the primary care setting may take more time and energy than other treatments or treatment of other conditions. However, the benefits are significant. For the physician, implementation of behavioral treatments from the onset may decrease repeated visits for acute headache. For the parent and child, a trusting relationship with the primary care physician often has been established already whereas referral to another professional may involve additional psychological and financial cost to the family. Provision of comprehensive treatment for headache at the time of initial presentation minimizes the suffering and disability children may experience.
In summary, behavioral treatments for both migraine and tension-type headache are effective, have few side effects, and can be quite efficient. These treatments are well accepted by most children and their families, but appear to be underused in pediatric and adolescent headache.
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