Headaches disorders are common, disabling conditions and the majority of people have experienced at least one headache episode in their lives. Tension-type headache (TTH) and migraine are the second and third most prevalent disorders in the world. In adults, episodic and chronic migraine (CM) affect 14.7% and 2% of the population, respectively, while episodic and chronic tension-type headache TTH (CTTH) affect 62.2% and 3.3% of the population, respectively. In studies restricted to children and youth the prevalence is lower but still rather high (9.2% for migraine, 15.9% for TTH and 0.9% for CTTH).
Current treatments for primary headaches include medications for the acute management of headache, such as triptans and nonsteroidal anti-inflammatory drugs, and prophylactic drugs with a variety of options, such as amitriptyline, topiramate, onabotulinumtoxin-A and β-blockers.
In recent years, non-pharmacological treatments have emerged as a valid option for headache disorders: these include nutraceuticals, dietary interventions, peripheral nerve or transcranial neurostimulation, and behavioral therapies. Behavioral approaches include different treatment interventions aimed at changing maladaptive behavior and ways of thinking that could enhance headache-related burden and pain. They include biofeedback, relaxation therapy, cognitive behavioral therapy (CBT) and mindfulness and ACT (Acceptance Commitment Therapy). Research has shown the effects of behavioral interventions in the management of primary headache disorders in adults and children. These interventions are commonly used in clinical practice, particularly in specialized units. They are generally well tolerated, can be jointly used with pharmacological therapies, and their use is suggested when medications have to be limited or avoided due to known side effects, contraindications, presence of medication overuse and is suitable for specific categories of patients, such as pregnant women and adolescents. However, the level of their effectiveness is still matter of debate. As evidenced from the recent literature, behavioral approaches produced sizeable effects on the classical primary endpoint in headache field, namely headache frequency, when used as preventive treatments in the management of patients with primary headaches. Irrespectively of the behavioral approach under examination, a reduction of headache frequency higher than 35% was found in more than half of studies, thus confirming that these approaches have the potential to positively impact on headache frequency in a way that is similar to the results seen in medication trials. These assumptions seem particularly relevant for migraine, as the majority of the studies included patient with migraine headaches, both episodic and chronic forms. In addition to this, these approaches produce a valuable impact also on some patient-reported outcomes that are generally used in headache research as relevant secondary endpoints, such as disability and QoL levels and depression, anxiety, and self-efficacy scores, as well as intake of acute medications. Behavioral approaches deserve a particular attention in the fields of their clinical application and of research in primary headache disorders, for different reasons. In recent years these treatments gained popularity among patients, which often perceived conventional treatments as ineffective or too expensive. Moreover, recent reports show that behavioral approaches have a strong evidence of efficacy to such a degree that they do not deserve being considered as (only) alternative or complementary to pharmacological treatments for headaches. Also, the different behavioral treatments generally do not carry the burden of neither side effects that are often associated to pharmacological prophylactic treatments nor their contraindications. All these aspects make behavioral therapies an important option in the treatment of patients with primary headaches – also in the most problematic forms such as chronic migraine with or without medication overuse – and may be considered in clinical practice as first options particularly in specific categories of patients, such as those with other chronic conditions and-or polypharmacy, pediatric patients and pregnant women in which the use of prophylactic compounds deserves careful consideration . Recent advances include research findings about the way behavioral treatments may exert their effect in primary headaches. Different mechanisms of action have been hypothesized. It is reasonable that no single causative effect, but rather a combination of them, may be involved. Behavioral treatments produce a reduction of stress, an increased sense of self-efficacy (i.e. the confidence in one’s ability to manage different aspects of his/her life), and reduce the external locus of control (i.e. the belief that nothing can be done to control life events). The joint effect of these factors may promote a reduction of clinical symptoms by enhancing the way in which patients experience pain perception and intensity. Several data suggest that behavioral treatments are also useful in reducing depression and anxiety levels, so commonly associated to poor prognosis in headache patients. The improvement in the above mentioned abilities are likely to determine an improvement in pain coping strategies and in reducing the catastrophizing attitude to pain. The biological mechanisms underlying all the above discussed aspects have been recently investigated. Neuroimaging findings demonstrated the impact of behavioral treatments, and of mindfulness in particular, in producing functional modifications in those brain areas involved in the cognitive and affective components of pain. Different neuroimaging studies showed increased activity in the anterior cingulate cortex and anterior insula, orbito-frontal cortex activation and with thalamic deactivation, thickening of cortical regions associated with pain processing, reduced activation in the amygdala, hippocampus, and emotional/evaluative regions of the prefrontal cortex, as well as increased activation in the mid-cingulate cortex, thalamus and insula. Furthermore, initial evidence exists on the ability of mindfulness to impact on interleukine-6, a marker of inflammation that is deemed to play a role in the regulation of pain threshold and to facilitate pain signaling during the development of migraine headaches . More studies are needed to expand our knowledge on the mechanisms of action of behavioral approaches, as well to guide clinicians in choosing the different available behavioral approaches in their daily practice. More randomized controlled trials are needed to confirm the utility of the individual behavioral approaches, possibly with blindness of the neurologist in charge of patients’ selection and follow-up about the treatment allocation of each included patient and with prolonged follow up.
tel.+ 39 040 368 343