The Journal of the Arkansas Medical Society Med Journal Aug 2019 Final 2 | Page 10

Behavioral Modifications (BM) – Headache Management
Jhablall Balmakund, MD
Professor of Neurology, Department of Pediatrics
University of Arkansas for Medical Sciences, Lowell
Abstract
M
anagement of migraine
and tension-type head-
aches (TTH) can be chal-
lenging. Medications may or may not be help-
ful, may cause side effects, or may worsen head-
aches. Behavioral Modification (BM), with or with-
out medication, will expand treatment options. Care
providers are frequently reminded about the risks
and benefits of medications. Patients and caregiv-
ers are becoming increasingly wary of medication
side effects and would like to avoid them. It is rec-
ommended that care providers encourage patients
to decrease their dependence on medication and
increase BM therapy. Caregivers are reassured that
medication is an option if BM is ineffective.
Introduction
BM may play a role in headache management.
It has been empirically validated for migraine and
tension-type headache (TTH). Meta-analyses yield-
ed a 37-50% reduction in tension-type headache,
compared to 33% using amitriptyline. 1 Penzen DB
et al concluded that modifications in TTH manage-
ment would make standard behavioral treatments
available and conducive to primary care settings
where most patients receive treatment. 1
In November 2015, the Food and Drug Ad-
ministration issued strong caution to manufactur-
ers of over-the-counter acetaminophen about po-
tential liver injury when the drug is used in larger
quantities. 2 The FDA has also warned that non-
aspirin, Nonsteroidal Anti-Inflammatory Drugs
(NSAIDS) increase the chance of a heart attack or
stroke. 3 A discussion of non-medicinal therapies
can be challenging when medication is available
that may work almost immediately. This challenge
may be less daunting with the use of motivational
decision making:
1) Use open communication and coordination
between patients and care-providers.
2) Encourage patients/caregivers to come up
with their own approach after agreeing on the
goals of management.
3) Discuss these therapies as part of the man-
agement.
4) Set realistic goals.
5) Take into account the patient’s comorbidities
and medications.
6) These modalities of care may require a trial of
weeks or months.
7) Use medication after these therapies have not
met the expected treatment goals or when
appropriate.
8) A tincture of time for some symptoms, includ-
ing headache, may suffice.
9) Many of these modalities of care are benefi-
cial to health and general wellbeing. It may
be helpful if insurance companies suggest
an initial trial of non-medicinal therapy in the
appropriate headache patient before medi-
cation use.
Patients may prefer non-medicinal interven-
tions for a variety of reasons including poor toler-
ance or response to medication, contraindications
to medication, pregnancy, planning to become
pregnant, and/or breastfeeding. Stress or deficient
coping skills may also make a patient better suited
for non-medicinal therapies. 4 BM may be used in
conjunction with medicine, devices, medical per-
sonnel, etc.
Behavioral Modification Therapies
The U.S. National Sleep Foundation recom-
mendations for sleep practices and tips for children
include the following: maintain a regular circadian
rhythm (a sleep routine) appropriate for age in a
comforting environment; enforce bedtime; avoid
naps, activities, devices and anything that may de-
lay or disrupt sleep; 5 understand that too much or
too little sleep are considered triggers for migraine,
so the bedroom should be primarily for sleeping
(TV, video games, cell phones, etc. should be re-
moved to avoid temptations).
34 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
The human body is about 60-65% water. A
consistently pale yellow to colorless urine may in-
dicate appropriate fluid intake. To avoid disruption
of sleep, most of the fluid should be drunk earlier
in the day. It has been speculated that water depri-
vation may play a role in migraine, particularly in
prolonging attacks. 6
A well-balanced diet at the appropriate
time and the avoidance of “high sugar foods”
may help prevent “hunger headaches. 7 ” Minimize
processed, fatty foods, fasting, or skipping meals.
There are a variety of chemicals and food additives
that may trigger a headache. Higher levels of lip-
ids and free fatty acids increases platelet aggre-
grability associated with decreased serotonin and
heightened prostaglandin levels. This combination
may provoke vasodilatation, the precursor of mi-
graine headaches. 8
Both the U.S. Department of Health and Hu-
man Services and the American Academy of Pe-
diatrics recommend a combination of aerobic and
anaerobic activity for 60 minutes daily. 9-10 This
should be age-appropriate and tailored to the in-
dividual’s ability to strengthen muscle and bone. 10
Randomized controlled and non-controlled tri-
als have demonstrated that exercise may be as-
sociated with reduction of migraine intensity and
migraine-related disability. Darabaneanu et al
found that the mean number of headache days
per month, duration, and intensity decreased in the
group that exercised compared to control after 10
weeks of exercise.
Triggers provoke the cascade of events that
culminate in a headache. They may be inconsis-
tent, require a “cofactor,” dose dependent, or have
a delayed effect making avoidance or identification
a challenge. These triggers may have an additive
effect, which is especially seen in female headache
patients during their menses. 4
Participation in activities that are enjoyable
and relaxing, while not being harmful or de-
stroying property, may help decrease the focus
on headaches.
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