Background
It has been estimated that globally, the percentage of the adult population with an active headache disorder is 46% for headache in general, 11% for migraine, 42% for tension-type headache, and 3% for chronic daily headache [
1]. In the World Health Organization (WHO) ranking of causes of disability, headache disorders are in the 10 most disabling conditions for both genders, and the 5 most disabling conditions for women. Migraine has been ranked among the diseases causing the greatest degree of handicap, together with conditions such as quadriplegia, dementia and active psychosis [
2].
A recent large study of the triggers of migraine attacks found 76% of migraineurs reported triggers when asked, and this figure rose to 95% when individuals responded to a specific list of triggers [
3]. The most common headache triggers are: (i) stress and negative emotions; (ii) sensory triggers (flicker, glare, eyestrain, noise, odours); (iii) hunger; (iv) lack of sleep or excess of sleep; (v) food (particularly chocolate, cheese) and drink; (vi) alcohol; (vii) menstruation; and (viii) weather (cold, heat, high humidity) [
4]-[
6]. Many other factors have been noted including exercise, fatigue, sexual activity, and head and neck movement. A number of studies have investigated whether migraine and tension-type headache have the same or different triggers, and most have failed to find differences [
7]-[
9]. Some more recent studies have found differences with light, odours, hunger, weather and smoke being reported more commonly in migraine than tension-type headache, and head and neck movement being more common in tension-type headache [
10],[
11].
Advice to identify and avoid triggers as a good means of preventing headaches, has been standard practice for decades. Researchers regularly make this point, for example, “comprehensive migraine treatment programs emphasize awareness and avoidance of trigger factors as part of the therapeutic regimen” [
12]. One of the ‘seven elements of good headache management’ listed by WHO is “identification of predisposing and/or trigger factors and their avoidance through appropriate lifestyle change” [
13]. This advice appears on numerous internet sites. For example, the American Headache Society website includes a handout entitled ‘Trigger Avoidance Information’. Headache Apps are now available for iPhones and iPads that encourage trigger avoidance (e.g.,
iManage Migraine, Merck & Co).
We have published three recent reviews arguing against counselling avoidance of all headache triggers [
14]-[
16]. It is not possible to completely avoid all potential headache triggers as they are so diverse; and attempting to do so could result in a restricted lifestyle [
3]. It has been pointed out that the effort to avoid every potential headache trigger may itself be stressful [
17]. Furthermore, advice to avoid triggers may lead to reduced internal locus of control for headaches, with attendant adverse effects on self-efficacy, particularly concerning perceived capacity to cope effectively with triggers [
18].
In the chronic pain literature, fear-avoidance models have been developed, which contend that individuals who confront their pain are considered more likely to adaptively resume physical and social activities, whereas those who respond to pain with anxiety and avoidance are considered more likely to enter a self-perpetuating vicious cycle that maintains and exacerbates pain perception, leading to chronic pain and related disability [
19]. In the stress literature, it has been argued that research findings indicate that coping with stress generally takes one of two routes, avoidance or approach, and the evidence demonstrates that the avoidance coping pathway is not adaptive, with a few important exceptions [
20]. It has also been argued that higher levels of ‘experiential avoidance’, a type of avoidant coping, are associated with higher levels of general psychopathology and a lower quality of life [
21].
The anxiety literature has demonstrated that short exposure to anxiety-provoking stimuli results in increased subsequent anxiety responses to the stimuli, whilst prolonged exposure results in decreased subsequent anxiety responses [
22]. It is short exposure, resulting from attempts to avoid, or escape from, anxiety-eliciting situations, that underlies the maintenance of fears and phobias. In contrast, exposure-based approaches have been used with great success to treat a wide range of anxiety disorders [
23]. A unified treatment approach for emotional disorders which includes preventing emotional avoidance (including behavioural avoidance and cognitive avoidance) and facilitating emotional exposure has been proposed [
24].
A series of studies has investigated the relationship between length of exposure to various headache triggers and the capacity of the trigger to elicit head pain. In participants exposed to the experimentally-validated trigger of ‘visual disturbance’ [
25] for one of five durations (‘none’, ‘very short’, ‘short’, ‘long’ and ‘very long’), nociceptive response was greater for the ‘short’ exposure condition than the ‘none’ and ‘very short’ exposure conditions; but the nociceptive response in the ‘very long’ condition was less than in the ‘short’ condition [
26]. In summary, the results were consistent with the anxiety literature in that short exposure increased nociceptive response whereas very long exposure decreased nociceptive response. The study was repeated for the validated headache triggers of noise [
27] and stress [
28] with similar results. In a study in which migraine and tension-type headache sufferers attended the laboratory for six sessions of exposure to visual disturbance, ratings of visual disturbance, negative affect and headache intensity in response to the trigger, decreased from baseline by 44%, 54% and 63%, respectively, demonstrating desensitisation [
29].
The arguments against advising avoidance of all headache triggers, and the findings linking prolonged exposure to decreased trigger potency, have led to us developing an alternative approach to trigger management called
Learning to Cope with Triggers (LCT). The word ‘cope’ is used because of the insights that can be derived from the stress literature which demonstrate that no single coping strategy can be selected as the best way of coping with stress for all situations and across time, but reviewers have concluded that approach strategies generally are more adaptive than avoidance strategies [
30]. We have argued that similarly, no one strategy can be singled out as the best way of managing all headache triggers. Sometimes avoidance will be the strategy of choice but more often, approach/engagement/exposure strategies will be more effective.
Following publication of three reviews advocating the LCT approach to trigger management, advice in the literature is now changing [
31]-[
33]. For example, the European Federation of Neurological Societies guidelines on the treatment of tension-type headache include “Identification of trigger factors should be performed, as coping with trigger factors may be of value” [
31].
We recently published a study designed to evaluate the traditional advice to headache sufferers to avoid all triggers (‘Avoidance’) on the one hand, and LCT that included graduated exposure to selected triggers to promote desensitisation on the other hand [
34]. Individuals (84 female, 43 male) with migraine and/or tension-type headache were assigned randomly to one of four groups: Waiting-list (Waitlist); Avoidance; Avoidance combined with CBT (Avoid + CBT); and LCT. Changes in headaches and medication consumption (in parentheses) from pre- to post-treatment were (a minus sign indicates improvement): Waitlist, +11.0% (+15.4%); Avoidance, −13.2% (−9.0%); Avoid + CBT, −30.0% (−19.4%); and LCT, −35.9% (−27.9%). Avoidance did not statistically differ significantly from Waitlist on headaches or medication use, but LCT differed significantly from Waitlist on both measures. Avoid + CBT significantly differed from Waitlist on headaches but not medication consumption. In summary, the study failed to find support for the traditional approach to trigger management of advising avoidance, but LCT emerged as a promising strategy.
Trigger management is only one aspect of a comprehensive approach to the treatment of headaches. Behavioural interventions have been shown to be quite efficacious for the treatment of headaches. A summary of meta-analytic reviews for behavioural treatment of migraine (thermal biofeedback, electromyographic - EMG - biofeedback, CBT, relaxation training) and tension-type headache (EMG biofeedback, CBT, relaxation training) concluded that average improvement ranged from 33% to 55%, compared with 5% for no-treatment controls for migraine, and from 35% to 55%, compared with 2% for no-treatment controls for tension-type headache [
35]. We evaluated our version of CBT for migraine and tension-type headache in a randomised controlled trial and found no differences as a function of diagnosis [
36]. CBT was associated with the following changes: (i) average decrease in headaches of 68% post-treatment, and 77% at 12-month follow-up; and (ii) average decrease in medication of 70% post-treatment. The average decrease in headaches at post-treatment of 68% (95% CI, 46.44 – 89.56) compares with the range of 33% to 55% from the review [
35].
This study will integrate LCT into our version of CBT (LCT/CBT), and evaluate the efficacy of this new approach in anticipation of enhancing the effectiveness of CBT. LCT/CBT will be compared with CBT combined with the standard approach to trigger management of avoidance (Avoid/CBT), and with Waiting-list control (WL). The study will test the following hypotheses:
1.
LCT/CBT will result in greater decreases on the primary outcome measures of headaches, medication consumption and headache disability, than Avoid/CBT and WL.
2.
LCT/CBT will result in greater increases on the secondary outcome measures of self-efficacy, internal locus of control, and quality of life (less restricted lifestyle), than Avoid/CBT and WL.
The study will also investigate predictors of response to treatment and explore client-treatment matching hypotheses, such as whether participants who have a small number of triggers all of which are avoidable, would respond better to Avoid/CBT than LCT/CBT, whilst the reverse would be the case for participants who have more or less avoidable triggers. The response of migraine versus tension-type headache will be investigated, but there are no specific predictions related to diagnosis as the triggers of the two types of headaches are similar although not identical [
10],[
11].
Discussion
Headache disorders are among the most common disorders of the nervous system, causing substantial disability in populations throughout the world [
13]. This has resulted in the
Global Campaign against Headache Disorders: “Lifting the Burden”, launched jointly by WHO, International Headache Society, World Headache Alliance and European Headache Federation [
61],[
62]. On 17th October 2011, in recognition of the importance of headache as a pain disorder, the International Association for the Study of Pain launched the
Global Year Against HEADACHE Oct 2011-Oct 2012.
An extensive literature has accumulated demonstrating that various behavioural treatments are efficacious for both migraine and tension-type headache. The United States Headache Consortium developed evidence-based guidelines for the treatment of migraine based on an extensive review of the medical literature and compilation of expert consensus, and found Grade A evidence (‘multiple well-designed randomised clinical trials, directly relevant to the recommendation, that yield a consistent pattern of findings’) in support of behavioural treatments (thermal biofeedback, EMG biofeedback, CBT and relaxation) for migraine [
63]. Nevertheless, there is room for improvement of behavioural interventions.
The proposed research represents arguably the first attempt to improve the efficacy of CBT for headaches. It does so by incorporating into the approach a method of trigger management that has been shown to be superior to the traditional method of trigger management of encouraging avoidance of all triggers. The proposed research is an efficacy trial and if the results are as predicted, then effectiveness research should follow (how well it works in the field).
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
PM, PG, SB and JR conceived and designed the study and obtained funding. SM, SB-B and AB are conducting the study with support from PM, PG, SB and JR. SM is the Project Manager, AB is the Project Coordinator, and SB-B played the lead role in designing the e-diaries. PM drafted the paper, and all the authors contributed to the manuscript. All authors read and approved the final manuscript.