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Migraine? Relief Is Heading Your Way

Behavioral Therapies

Drugs are not the only way to treat migraines, though, and all of the experts consulted for this report stress the importance of combining them with other ways to manage migraines.

"I think the most important treatment tool is education," Mannix says. "You can't educate yourself out of an acute attack, but you can lessen the number and severity of attacks by being more knowledgeable about what to take and when to take it. The patients who really get involved in their care, who figure out the lifestyle modifications that they have to make and maintain, do better than those who say, 'Doctor, give me a pill.'"

One technique already in use by many headache specialists is biofeedback. Stress is a major trigger for migraine attacks, and biofeedback machines combat stress by training people to use effective relaxation practices.

"One recent report found biofeedback ineffective, but that goes against everything we know as migraine specialists," Mannix says. "It is not one of those decisions like, 'I am in the middle of acute attack, do I want biofeedback or Zomig?' But it is part of the things that patients have to do. It is something you actively participate in -- you learn about your responses to different conditions that add to or trigger migraines. Those type of things, as well as acupuncture and alternative medicines, need to be combined with good pharmaceuticals. It is not an either-or thing."

Psychologist Donald B. Penzien, PhD, is director of the Head Pain Center at the University of Mississippi Medical Center in Jackson. He is a member of the committee that recently drew up evidence-based guidelines on nondrug migraine treatments for the U.S. Headache Consortium.

"Once a really bad headache hits, there is not much to do, so prevention is the name of the game in behavioral therapy," Penzien tells WebMD. "We treat patients with very difficult ... problems who don't respond well to migraine drugs. What we find is that for many patients the best results come from everyday preventives -- the medicines that stop breakthrough headaches -- and from nondrug treatments. These nondrug treatments focus on finding out what are your risk factors and using relaxation skills that can help avoid triggering a migraine. Our patients tend to do best with this combination."

The Headache Consortium panel evaluated published evidence for all nondrug migraine treatments and found that the evidence supporting biofeedback in combination with relaxation training -- or relaxation training in combination with cognitive-behavioral psychotherapy -- was as good as the evidence supporting medical migraine treatment.

"My personal push is, we know these things are useful, and most specialty headache centers have years ago integrated these techniques," Penzien says. "They have a psychologist or social worker on staff who can offer interventions like these -- if you are one of the patients who gets to see the specialist. But this is a relatively small proportion of patients. And these interventions tend to be time consuming, and not every physician is going to make that referral to the mental health specialist. But there is information we have learned that can be useful to a whole lot more patients. The average person with migraine might be able to avoid headaches if he or she practiced some of these techniques. So our big push is to take these interventions out of [the specialty] clinic and put them into the primary care clinic."

Obviously, not many primary care doctors have the time to teach behavioral therapy. So Penzien and his co-workers are developing new tools to let patients do a lot of the training themselves.

"The concept is CD-ROM or Internet packages that could be supervised by a doctor or psychologist but which are primarily self-help programs," he says. "These things are not rocket science. This is a very basic level of information that can help people. The techniques themselves are being improved, and although we've come a long way, we've got a long way to go."

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