US map with migraine, tension-type, and cluster headache percentages

So You Want Me to See a Health Psychologist? The Role of Psychology in Headache Care

Amy S. Grinberg
Amy S. Grinberg

Amy S. Grinberg, PhD
Clinical Health Psychologist
Headache Centers of Excellence; Psychology Service VA Connecticut Healthcare System
Founder, Ease the Pain Psychology

Almost everyone encounters a headache at some point in their life. However, headache disorders, such as migraine, tension-type headache, and cluster headache, are more than “just a headache”. They are complex neurological diseases with commonly associated symptoms including nausea/vomiting and sensitivity to light and sound. Headache disorders impact all aspects of life, including work, family, and social relationships.

There is a range of medical treatments available to either prevent headache symptom development or to stop symptom progression. However, many patients experience medication side effects, contraindications to pharmacotherapy, or simply express a preference for non-medication treatment options.

You want me to see a psychologist?
There is a long-standing history of stigma related to headache disorders. The “invisible” nature of the disease contributes to the negative perceptions people have about them. As providers, we must be cognizant of the language used both with the patients we treat but also amongst our colleagues to ensure we are accurately capturing our patients’ experiences and the disabling nature of their headache disorder. For example, rather than referring to a patient as a “migraine sufferer” or “migraineur”, consider describing them as “a person with migraine”.

Understandably, many individuals who are referred to see a psychologist for headache management are skeptical and apprehensive since they think that this means no one believes that their pain is real or that it is “just in their head”. Validating a patient’s concerns and providing a clear rationale for treatment is paramount. Explaining how biopsychosocial factors are at play may help with treatment buy in. It can be helpful to highlight the complexities of headache disorders and the different ways both internal and external factors contribute to the perception of pain and associated symptoms. Many patients articulate their difficulties with the physical symptoms they have yet they are likely to also experience negative thoughts, distressing feelings, and engage unhelpful behaviors, all of which can have an impact on their headache symptoms. You may also wish to consider including family members in your treatment to support your patient.

What are behavioral treatments for headache?
A health psychologist who specializes in headache may consider a range of Level A, evidence-based treatment approaches including biofeedback, relaxation training, and Cognitive Behavioral Therapy (CBT). Research shows that combining medical treatment with behavioral interventions is the most effective.

Biofeedback teaches patients to observe and control their physiological responses, such as heart rate, muscle tension, and respiration, which can reduce the frequency of headache pain and associated symptoms. Regular use of relaxation training helps patients bring calmness into their nervous system. During Cognitive Behavioral Therapy individuals learn various self-management strategies to decrease the frequency and severity of their headache pain and symptoms as well as improve their quality of life. These may include ways to manage stress, problem-solve, improve sleep, and enhance any abortive medications, in addition to promoting other healthy lifestyle recommendations, such as maintaining regular meals, consistent hydration, and limiting caffeine and alcohol intake.

Can I provide behavioral treatments for headache disorders via telehealth?
Behavioral treatments for headache are especially amenable to telehealth adaptations and may increase access to much-needed health psychology treatment. Within the Veteran Health Administration (VHA) over 350,000 Veterans received care for their headache disorder each year. To meet the growing needs of Veterans with headache disorders, the VHA established the congressionally mandated Headache Centers of Excellence. The Headache Centers of Excellence place a particular emphasis on increasing telehealth and access to health psychology services. The current SARS-CoV-2 (COVID-19) pandemic has led to significant increases in the provision of telehealth, yet even prior to the current pandemic, many patients have voiced a preference for non-pharmacological treatment and the use of telehealth since it allows them to receive care at a time that is convenient for them.

In sum, headache disorders are complex neurological diseases and more than “just a headache”. Health psychologists are often key members of an interdisciplinary treatment team and are therefore uniquely positioned to provide patient-centered care to address all facets of a patient’s concerns. A key part of behavioral treatment for headache disorders involves empowering the patient to take an active role in their headache management and fostering increases in self-efficacy.

References
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U.S. Department of Veteran Affairs and Department of Defese (2020). VA/DoD Clinical Practice Guideline For The Primary Care Management of Headache. https://www.healthquality.va.gov/guidelines/pain/
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Grinberg AS, Fenton, B.T., Lindsey, H., Ney, J.P., Penzien, D.B., Seng, E.K. & Sico, J.J. Understanding the prevalence and geographic distribution of headache disorders within the Veterans health administration. Headache. 2019;59(S1):P185.

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Headache Classification Committee of the International Headache Society (2018). The International Classification of Headache Disorders, 3rd edition.” Cephalalgia 38(1): 1-211.

Holroyd, K., et al. (2008). Behavioral management of headaches. Wolff’s Headache and Other Head Pain. S. Silberstein, R. Lipton and D. Dodick. New York, NY, Oxford University Press: 721-746.