Professor Paul R. Martin1
Professor Graham Meadows1,2
Professor Leon Piterman1
Dr Lillian Nejad1
Assoc. Professor John Reece3
Professor Jeannette Milgrom4
1 Monash University
2 Southern Health
3 RMIT University
4 University of Melbourne
beyondblue Victorian Centre of Excellence
Project completion year
Chronic headache is extremely common and can be very debilitating. This statement is true for both the major types of primary headache – migraine and tension-type headache. Chronic headache is associated with very high direct and indirect costs to society. Research studies have shown that individuals with chronic headache have a much higher risk of also suffering from mood disorders (i.e., depression). Anxiety disorders are also common in this group. Cognitive behaviour therapy (CBT) has been demonstrated to be a highly successful form of treatment for chronic headache. This approach includes a number of methods such as relaxation training, pain management techniques, and techniques designed to challenge and modify the dysfunctional thoughts and beliefs that are associated with headaches and the triggers of headaches, such as stress. Evidence suggests, however, that individuals who suffer from chronic headache and depression respond less well to CBT.
The main aim of this research is to develop a new CBT protocol for the integrated treatment of co-morbid chronic headache and depression, and to evaluate it. Participants for the research were recruited through general practices and other methods. To be eligible for the trial, participants needed to be between 18 and 65 years of age, and diagnosed as suffering from chronic headache (tension-type headache or migraine, for at least 12 months), and Major Depressive Disorder.
The average decrease in headache activity in the CBT group from pre- to post-treatment was 45.0 per cent, compared to a 0.4 per cent increase for the RPC group, as measured by headache diaries. To place this reduction in perspective, Rains et al (2005) summarised the results of five meta-analytic reviews for behavioural treatment of migraine and four meta-analytic reviews for behavioural treatment of tension-type headache and concluded that average improvement ranged from 33 per cent to 55 per cent. Hence our results are in the middle of this range, despite the fact that all our participants were also suffering from Major Depressive Disorder. Amitriptyline is considered a leading prophylactic for both tension-type headache and migraine (Jackson et al, 2010), and has been shown to be associated with a 27 per cent decrease in headaches (Holroyd et al, 1991).
The CBT group was associated with a 57.1 per cent decrease in depression, compared to a 13.4 per cent decrease for the RPC group, as measured by the Beck Depression Inventory II. The mean BDI scores of the CBT group were 30.6 (‘severe depression’), 13.1 (‘mild depression’), and 10.2 (‘mild depression’), at pre-treatment, post-treatment and 4-month follow-up respectively. These findings were repeated on an alternative measure of depression (Patient Health Questionnaire-9) for which depression decreased 61.5 per cent for the CBT group and 27.5 per cent for the RPC group.
Other measures showed strong benefits for the CBT group. For example, anxiety decreased by 49.4 per cent in the CBT group compared to 13.9 per cent in the RPC group, as measured by the Beck Anxiety Inventory. Medication consumption decreased by 42.1 per cent in the CBT group compared to 15.9 per cent in the RPC group, as measured by medication diaries. All the differences between the CBT and RPC groups were statistically significant except one which was a trend.
The project developed a 162-page manual for the treatment of co-morbid chronic headache and depression, including therapist notes, client handouts and a relaxation CD. 90 clinical psychologists in independent practice were trained in the techniques utilised in the manual. The project progressed to demonstrating the effectiveness of this treatment approach for reducing headaches and depression in individuals with co-morbidity. Much previous research has found that individuals with even mild to moderate depression do not respond well to the traditional CBT approaches for headaches, so to achieve good reductions in headaches in individuals suffering from Major Depressive Disorder is a highly significant advance.
The results are particularly noteworthy as treatment was administered by clinical psychologists in their independent practices rather than research staff operating in a university environment. The clinical psychologists had little experience in treating headaches but had attended a one-day workshop presented by the Primary Investigator. Hence the usual criticism of treatment research that it might not translate into the field does not apply to these findings as the research was carried out in the field.