Psychiatric comorbidities, like depression or anxiety disorders, are well known and the combination of anxiety and depression was reported in about 20% of the general population in France [
28]. Psychiatric comorbidity in general is recognised as a problem in primary care. General practioners reported that those patients are requiring more care, more time, and more frequent consultations [
29]. As a consequence of more difficulties to refer such patients to specialists GPs are unsatisfied with the relationship to mental health care providers and ask for better collaboration with them [
29]. Therefore, the access for headache patients to psychologists in headache centres is helpful. Transformed migraine seems to have the highest rates of psychiatric comorbidity (78%) compared to chronic tension-type headache (64%) [
30]. Involvement of psychiatric disorders was reported for 68% of MOH patients [
31,
32]. However, looking at the involvement of psychological factors in headache, we are faced with a lot of different dimensions: from life events to psychological trigger factors, from stress to personality characteristics [
33]. As there is a connection between headache and other pain disorders and patients’ psychological health and quality of life, psychologists play an important role in the evaluation of headache patients’ as well as in therapy. A psychological intervention might help to address “modifiable” risk factors for headache chronification [
34], such as attack frequency, obesity, medication overuse, stressful life events, caffeine overuse, snoring, and other pain syndromes. Psychological intervention should not only be considered if psychopathology has been diagnosed, but also if psychopathology represents a risk for headache chronification [
35]. Furthermore, education and self-management are important to all patients with headache and therefore an important part of the treatment which can be done by psychologists. This includes lifestyle education, self-management, handling medication and risks of medication overuse. Even though detailed scientific data are sparse, psychologists are considered important members of multidisciplinary teams. Non-pharmacological treatments are acknowledged as preventive methods especially for migraine according to neurological guidelines [
36]. Psycho-physiological (relaxation often utilised with biofeedback) and cognitive-behavioural training are the core methods of this approach [
36‐
40]. These methods, usually offered in 8–12 (individual) treatment sessions, can be combined, condensed to home-based training [
38,
41] and transformed into self-management formats. Such self-management training achieves 42% responders regarding migraine attack prevention (mean change 23%, effect size .6). Furthermore, marked increase in perceived control over and self-confidence in attack prevention and improved migraine-specific quality of life over time were also reported when offered by trained patient trainers supported backstage by a psychologist [
42‐
44]. Essential psychological issues comprise self-efficacy, perceived control and catastrophizing, and the patient’s readiness to change [
40] and avoidance [
41] should be considered. Self-efficacy mediates successful headache management and is related to perceived own control over headache [
42‐
47]. Catastrophizing, on the other hand, is associated with reduced functioning and quality of life in severe migraine [
48,
49] and with more pain and disability in chronic pain [
50,
51]. The focus should be not only on the avoidance of headache triggers, but the therapy also working on active management and coping of headche [
45].
The psychological work may be enhanced by the aid of testing evaluating psychiatric disorders (e.g. Mini Psychiatric Interview), personality (e.g. Shedler–Westen Assessment procedure) and cognitive factors as locus of control and self-efficacy (e.g. Headache specific locus of control (LOC) Scale, Headache Management Self-Efficacy Scale). New aspects are the internet-based protocols for cognitive-behavioural self-management, guided training and treatment to be utilised as part of primary care, intermediate care and self-care, which are currently under the development and evaluation in the Netherlands [
52]. Of the three early attempts to utilise the internet for the purpose of self-help and behavioural management in primary headache, two suffered from a lack of diagnostic specificity and methodological limitations [
53,
54]. The best-designed study [
55] involved 156 participants with a reported medical diagnosis of either migraine or TTH in a randomised controlled trial with promising results but a drop-out rate of over 40%.