The effectiveness of cognitive-behavioral therapy to migraine, tension type headache and temporomandibular disorders - Evidence based review
 TSAKONA I., SKAPINAKIS P., DAMIGOS D., MAVREAS V.

Worldwide, despite the advances in understanding anatomy and physiology associated with pain, pain continues to be a significant problem for many people. In the previous fifty years, problems of chronic pain had been evaluated and therefore treated biomedically as a symptom of underlying pathology.

However, the last two or three decades, important improvements have been noted in the scientific discipline-field of psychotherapy. Cognitive-Behavioral Therapy (CBT) is the common standard of psychosocial intervention for pain (Morley et al., 1999, Melzack & Perry, 1975, Weisenberg, 1980 & Gil et al., 1996).

Cognitive-behavioral therapeutic techniques (for instance, progressive muscle relaxation training, guided imagery, attention diversion strategies, biofeedback training, stress management and cognitive restructuring) have been examined systematically in various randomized controlled trials (RCTs) as modes-methods for the management of pain in patients suffering from tension type headache (TTH), migraine and temporomandibular disorder (TMD).

The common characteristics to these three disorders are the intensity of pain and associated behavioural and psychological dysfunction, pain interference and recurrence. This paper aims to summarize and examine information about the effectiveness of CBT on TTH, migraine and TMD.

In summary, the available data from the 17 trials, which were included in this evidence-based review, indicate that, either cognitive or behavioral techniques are effective methods on pain reduction for TTH, migraine and TMD. The findings from this review suggest that the combination of CBT techniques (for instance, relaxation therapy plus stress management and biofeedback) results in a significantly reduction on levels of pain when compared to placebo or usual therapy.

In addition to the overall findings referred to before, there are also specific elements that seem to improve the rates of reduction on pain. For example, the cognitive restructuring seems to be significantly effective on TMD while relaxation therapy, guided imagery and biofeedback seems to be importantly effective on the other two psychophysiological disorders, on migraine and TTH.

It is important to bear in mind that similar techniques have been shown to be effective on the above psychosomatic syndromes in other systematic reviews and leading articles (for eg., Baumann, 2002, Andrasik, 2004, Lipchik & Nash, 2002, Holroyd & Drew, 2006).

Another positive outcome of this review is the utilization of alternative types of CBT's administration. The original element of Devineni & Blanchard (2005) was that behavioral interventions were administered via the Internet with minimal e-mail assistance. Overall, the results of this attempt suggest that the above method can produce significant improvements in pain symptoms and functional impairment among headache sufferers and that these gains are sustained over at least two months.

Another alternative type of CBT's administration is the self-administered treatment, which seemed to be equally effective to the clinical treatment and superior to the control treatment (McGrath et al., 1992). The home study program included a workbook and audiotapes, with supervision provided via weekly telephone calls. Home study proved as effective as therapist-administered treatment (66% versus 44% of adolescents showing significant migraine reductions, respectively), and both programs were more effective than a one-session control condition that included weekly phone calls.

Self-management training include information about headaches, migraines and TMD as well as information about the principles of behavioral management, identification of headache and migraine triggers and pain coping strategies for living with these disorders (Holroyd & Drew, 2006).

The above findings are important because migraine and tension-type headache are common disorders to adolescents and both the Internet program and self-administered program were more time-efficient and with less cost than traditional clinical treatment (Devineni & Blanchard, 2005, McGrath et al., 1992).

According to guided imagery, the results from several trials indicate that the imagery groups were superior to the placebo control group on both experimental and clinical pain. The finding that imagining an event which is consistent with the experience of pain improves performance on experimentally produced pain replicates previous finding in this area (Andrasik, 2004, Lipchik & Nash, 2002). What seems to be important in improvement is how often subjects used the strategy at non-pain times (Brown, 1984).

The results of our analysis generally agree with the results of previous reviews (Holroyd & Drew, 2006, Penzien, 2004, Lipchik & Nash, 2002, Andrasik, 2004, Andrasik, 2003, Baumann, 2002), especially regarding the important role of combining the cognitive and behavioral techniques on pain reduction. Increasingly, researchers are seeking ways of making behavioral and cognitive treatments, for migraine, TTH and TMD, available to individuals who do not receive treatment due to the expense of treatment and inability to go to clinic.

So, cost-effectiveness studies should also be a priority in future research. It is also important to examine when and how to choose between drug and behavioral therapies or how to integrate the two. However, any intervention can also have negative effects so better information is needed about long-term effects of participation in different programs. Encephalos 2009, 46(3):121-128.

Key words: Migraine, tension type headache, temporomandibular disorder, cognitive-behavioral therapy.