Barriers to Behavioral treatment
Relaxation, mindfulness, biofeedback for migraine…. it’s all great but why is it so difficult to stick to it?
More skills, less pills. For many people with migraine, avoiding medications is a priority.And good news, many options are available to control migraines without medications. Diets seem to attract the most people, but the evidence for a food solution to migraine is still limited. It does not mean that it does not work though, but that would be a good topic for another blog.
The behavioral approaches supported by a strong scientific background include relaxation, cognitive behavioral therapy, biofeedback and trigger management. Mindfulness Based Stress Reduction is also under study and has been shown to work well for anxiety and chronic pain.
So, it seems like starting these healthy practices could really help. But here’s the issue: it IS DIFFICULT! Time is short, motivation varies and then boom, a migraine hits, destroying your focus for two or three days. And then you have to catch up, so no time for your relaxation session…I knew I was not able to do it! (discouraged sigh).
Is there some research on this very important topic? YES.
In a review published in Headache (our favorite journal), Matsuzawa and colleagues have reviewed the reasonswhy it is so difficult to keep regular practices for behavioral habits. Here is what they found:
|Barriers to adherence to behavioral approaches
«Why can’t I just stick to it?»
|Attitude and beliefs||I can’t do it
Everybody says it would be good to do this, but it will not work
I just can’t stop thinking, this is the way I am
I have no time to do this
I am not anxious, why should I do this
My anxiety is not the cause of my migraine
Meditation is esoteric and weird
|Stage of change and motivation||I am not ready to do this
Now is not the right time for me to make this change
I know I should do it but I just don’t feel like doing it
I feel forced to do it
|Lack of knowledge||I don’t know how to do this
I don’t believe that this approach could help migraine
Who will show me how to meditate?
This looks very complex…maybe not worth my time
|Locus of control
Internal versus External
|I cannot do this myself
The doctor has to fix my problem
|Self-efficacy||I believe I can do this and reach my goal|
|Coping styles||Avoidance: I can’t do A-B-C because it triggers migraine
Self-criticism: it’s my fault, I should be able to do this
Wishful thinking: eventually the pain will disappear
Social withdrawal: I’m worthless, my friends must be bored with me
|Expectations and acceptance||I just want this pain to be gone
If it can’t be perfect, it’s not worth it
I just cannot live with this pain, my life is a mess
I want to be like I was before, nothing less
**Adapted freely from Matsuzawa’s article combined with some quotes I hear in my office.
Wow, this table was a bit depressing to read, isn’t it?
But those thoughts and reactions are all very normal for a human being confronted with a problem (pain or something else).
Good news: there are solutions!
So, what can be done to overcome those barriers and successfully adopt some good habits that will decrease the migraine frequency? Here are some things that you and your health care provider could do to make progress (and yes, it is a long path).
|What can be done by the Patient|
|Learn more and be convinced||Get more information and learn about the technique you’re interested in. This will fuel your motivation.|
|Work on acceptance and adapt expectations||Realize that even if this situation is unfair, you still have to deal with it. Appreciate small successes and build your confidence.|
|Use a SMART approach
(google it for more details)
|Your goal should be Specific, Measurable, Achievable, Relevant, Time bound.|
|Consider Acceptance Commitment Therapy||This type of Cognitive Behavioral Therapy is designed to help you reset expectations….and feel better.
It can be done with a counsellor or as a group workshop.
|What can be done by the Health Care Provider|
|Tailor the treatment to each patient||Each patient has different coping styles, interests, social situations. Recommending relaxation to everyone is unlikely to work.|
|Discuss with your patient in more depth||Address your patient’s concerns. Evaluate their beliefs, perceptions and motivation.|
|Use scales to evaluate the situation||Some scales used in research can be filled by your patient to gage their self-efficacy, locus of control, catastrophizing thinking etc.|
|Use motivational interviewing||This well-known technique will enhance the quality of your interaction and increase the chance that the patient will progress|
|Build a network of resources||You will need allies to help your patient. Get to know your local network: workshops, counsellors, online programs etc.|
|Follow-up on your patient’s progress||If you recommend a technique and your patient commits to it, consider this as an important part of the plan, and follow-up at the next visit. If your patient is doing it, reinforce it. If it has been difficult, encourage and reassess.|
- Behavioral approaches can work to improve the migraine situation, but adherence (sticking to it) is not a natural easy thing.
- There are common human reasons why people find it difficult to commit to a healthy habit.
- There are also solutions, both on the patient and the provider’s side, to improve adherence and lead to success (less migraines, yay).
Did you find this article useful? Share and comment!
Dr Elizabeth Leroux, MD, FRCPC
Matsuzawa, Barriers to Behavioral Treatment Adherence for Headache: An Examination of Attitudes, Beliefs, and Psychiatric Factors, Headache, Jan 2019, 59 (1), 19-31
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