Cognitive Therapy and Research, VoL 1, No. 2, 1977, pp. 121-133
C o g n i t i v e C o n t r o l o f T e n s i o n H e a d a c h e '
Kenneth A. Holroyd, 2 Frank Andrasik, and Teresa Westbrook Ohio University
This study assessed the effectiveness o f a cognitively oriented stress coping training program designed to provide skills for coping with daily life stresses as a treatment for tension headache. Thirty-one community residents with chronic tension headaches were assigned to stress-coping training (N = 10), to biofeedback training (N = 11), or to a waiting-list control group (N = 10). Treatment procedures were accompanied by counterdemand instruc- tions designed to minimize the influence o f implicit demands for improved performance: Although only the biofeedback training group showed reduc- tions in frontalis electromyographic activity, only the stress-coping training group showed substantial improvement on daily recordings o f headache. These results were interpreted as provMing support for a cognitive approach to the treatment o f tension headache. Questions concerning the part played by nonspecific treatment factors in biofeedback training were also raised.
Headache may be the most commonly reported bodily complaint (Wolff, 1963). Survey data indicate that between 50% and 70% of adults experience headaches, 40% of which are tension headaches (Kashiwagi, McClure, & Wetzel, 1972). Of the 15 classes of headache identified by the Ad Hoc Com- mittee on Classification of Headache (1962) of the American Medical Asso- ciation, tension headache (also commonly termed muscle-contraction, psy- chogenic, or nervous headache) is the most frequently occurring. Tension headache is typically characterized by persistent sensations of bandlike pain or tightness located bilaterally in the occipital and/or forehead regions. It is gradual in onset and may last for hours, weeks, or even months.
'Appreciation is expressed to Dale Mattmiller, M.D., Jerry Noble, and Cheryl Richards, who assisted with the carrying out of this experiment. Grants from the Ohio University Research Committee and NIMH (1-R03-MH28939-1) to the senior author provided support for this study.
~Address all correspondence to Kenneth A. Holroyd, Department of Psychology, Ohio Uni- versity, Athens, Ohio 45701.
The exact etiology of tension headache remains unclear (Bakal, 1975). However, there is a general consensus that tension headache: (1) is an indi- vidual response to psychological stress (Ad Hoc Committee on the Classifi- cation of Headache, 1962; Wolff, 1963); and (2) may result from the sus- tained contraction of skeletal muscles about the face, scalp, neck, and shoulders (Bakal, 1975; Martin, 1972).
Supportive psychotherapy or other therapeutic interventions designed to reduce psychological stress precipitating tension headache play an impor- tant part in recommended treatment regimens (Martin & Rome, 1967; Wolff, 1963). For example, in a review of methods for managing tension headache, Wolff (1963) concludes that the greatest therapeutic benefit is likely to result from teaching the headache sufferer to "recognize his faulty attitudes, to change them and to adjust to what seem heretofore intolerable or hopeless situations" (p. 519). In spite of this generally accepted belief that tension headache results from failure to cope adequately with psycho- logical stress, there have been no attempts to evaluate the effectiveness of cognitive treatment approaches which directly attempt to improve the head- ache sufferer's ability to copy with stress.
There is considerable evidence suggesting that individual stress reac- tions are highly dependent on cognitive responses to the stress-eliciting situ- ation and thus might be modified with cognitively oriented intervention procedures (Janis, 1958; Lazarus, 1966; Meichenbaum, Turk, & Burnstein, 1975). In fact, recent research indicates that directive therapeutic proce- dures designed to alter cognitive responses to anxiety-arousing situations are effective not only for the treatment of clinical problems such as specific anxieties (DiLoreto, 1971; Goldfried, Linehan, & Smith, Note 1; Holroyd, 1976; Kanter & Goldfried, Note 2; May, 1975; Meichenbaum, 1972; Meichenbaum, Gilmore, & Fedoravicious, 1971; Osarchuk, 1974), stutter- ing (Moleski & Tosi, 1976), and unassertive behavior (Linehan & Gold- fried, Note 3; Thorpe, 1975; Wolfe & Fodor, in press), but also for provid- ing individuals with skills for coping with laboratory (Meichenbaum, 1975) and real life (Langer, Janis, & Wolfer, Note 4) stressors. The purpose of the present study was to evaluate the effectiveness of a cognitively oriented stress-coping training program designed to provide skills for coping with daily life stresses as a treatment for tension headache.
Headache sufferers received stress-coping training or biofeedback- assisted relaxation training, or they were assigned to a waiting-list control group. The stress-coping training program employed cognitively oriented therapeutic procedures (Beck, 1976; Goldfried, Decenteceo, & Weinberg, 1974; Meichenbaum, 1974) to teach individuals to identify their reactions to stress and to employ effective cognitive coping skills. The biofeedback- assisted relaxation training procedure, which was employed as a compari-
Cognitive Control of Tension Headache 123
son treatment, focused on teaching individuals to counter psychological stress by evoking a learned relaxation response (Stoyva & Budzynski, 1974; Stoyva, 1976). Both treatments were administered with counterdemand instructions (Steinmark & Borkovec, 1974) designed to minimize the influ- ence of implicit demands for improved performance. Although recent re- search suggests that the outcomes obtained with cognitive therapy proce- dures cannot be completely accounted for by the demand and expectancy effects of these treatments (Holroyd, 1976), biofeedback-assisted relaxation procedures have yet to be subjected to this test (Shapiro & Surwit, 1976). Thus, the part played by nonspecific treatment effects in the outcomes ob- tained with biofeedback-assisted relaxation training has yet to identified.
M E T H O D
Subjects
Newspaper, radio, and television announcements of a program teaching methods for control of headaches generated 103 respondents. From this group 31 persons reporting symptoms of tension headache (Wolff, 1963) with a regular occurrence of three or more headaches per week were identified. Evaluation by participants' physicians revealed none of these headaches to have an organic basis. Participants included 27 fe- males and 4 males with a mean age of 27 years and a mean duration of head- ache problem of 6 years. One participant was eliminated from each group prior to data analysis. The participant receiving stress-coping training dropped out after reporting herself headache-free at the third session. Although she reported still being headache-free at follow-up, she was not regarded as having completed treatment. In addition, one biofeedback reci- pient did not complete treatment because of schedule conflicts and one per- son in the waiting-list control group moved and could not be reached.
Procedure
Following initial telephone screening, participants were seen individ- ually by one of the senior authors, who obtained informed consent and a re- quired $5 deposit, administered pretreatment measures, and arranged to obtain diagnostic medical information. Individuals meeting the require- ments for participation were then assigned by a within-sample matching technique (Goldstein, Heller, & Sechrest, 1966) to stress-coping training (N = 10), biofeedback-assisted relaxation training (N -- 11), or waiting-list control (N = 10) conditions. Waiting-list control subjects were paid $10 for
124 Holroyd, Andrasik, and Westbrook
keeping accurate records of their headaches as well as offered treatment at the completion of the study.
Measures
Symptoms. For at least 2 weeks prior to receiving treatment, con- tinuing through 2-week posttreatment assessment, and for 2 weeks at a 15-week follow-up evaluation, participants maintained a Headache Data Card on which they rated the occurrence and intensity of headaches on an l 1-point scale (0--no headache, 10--incapacitating headache) every hour from 10:00 a.m. through 10:00 p.m. (Haynes, Griffin, Mooney, & Parise, 1975). An index of overall headache activity was calculated by summing headache ratings each day with weekly averages? In addition, participants' ratings of the frequency of occurrence of 18 common psychosomatic com- plaints were obtained on the psychosomatic checklist (Cox, Freundlich, & Meyer, 1975) at pretreatment, posttreatment, and follow-up assessments.
Frontalis EMG. Frontalis electromyographic activity was assessed during 5-minute resting periods at pretreatment evaluation and, for partici- pants receiving treatment, following each treatment session. This allowed an assessment of the impact of each of the treatment procedures on the muscle contraction responses that have been hypothesized to be crucial to the genesis and maintenance of tension headache (Martin, 1972). While participants rested in a heavily padded chair, frontalis muscle activity was monitored from forehead disk electrode placements (Budzynski, Stoyva, Adler, & Mullaney, 1973) directed to a Cyborg P433 myograph which dis- played an analogue signal proportional to mean peak-to-peak EMG fluctu- ations on a meter calibrated in microvolts. All readings were taken directly from the myograph meter with each reading representing the lowest micro- volt level occurring in the last 10 seconds of the 1-minute periods (Kotses, Glaus, Crawford, Edwards, & Scherr, in press). Similar readings were ob- tained during biofeedback training for participants receiving this treatment.
Additional Measures. Participant levels of trait anxiety (Spielberger, Gorsuch, & Lushene, 1970) and locus of control (Rotter, 1966) were assessed to provide measures that might be helpful in predicting individual differences in response to treatment. Two studies have found trait anxiety related to treatment outcome (McMillan & Osterhouse, 1967; Meichen- baum, Gilmore, & Fedoravicious, 1971) and it was suspected that internal clients might be more responsive to self-control procedures such as those employed in the present study.
3Average weekly headache activity scores (HA) were computed by the following formula: HA = (I X D) where I is intensity of headache and D is the hours of duration of headache. This index of headache is considered to he the most useful measure of headache activity as it incor- porates two separate dimensions of each reported headache.
Cognitive Control of Tension Headache 125
In order to assess participants' perceptions of the credibility of the treatment they received, they were required to evaluate the probability of their recommending the treatment to a friend suffering from headaches and how important they thought it that their treatment be made available to other headache sufferers on 5-point scales.
Treatment
Treatment procedures were administered during eight biweekly 45-minute individual sessions. Counterdemand instructions emphasizing that no improvement could be expected until the completion of treatment (Steinmark & Borkevec, 1974) were administered at the end of the first treatment session.
Stress-Coping Training. This treatment focused on altering maladap- rive cognitive responses that were assumed to mediate the occurrence of ten- sion headache. Specific procedures were adapted from cognitively oriented therapy procedures (Beck, 1976; Goldfried et al., 1974; Meichenbaum, 1974) and designed to maximize the occurrence of causal reattribution and the development of self-monitoring and cognitive coping skills as described below.
The rationale for treatment emphasized that disturbing emotional and behavioral responses are a direct function of specifiable maladaptive cogni- tions. It was emphasized that tension headache results from psychological stress and that stress responses are determined by cognitions about an event or situation. Several concrete examples were provided to illustrate the variety of events that can be perceived as stressful by different individuals and the way in which cognitions can induce psychological stress and head- ache. Unreasonable expectations (that one should be perfect or liked by everyone) were discussed and the manner in which they predispose individuals to experience stress was illustrated. Thus clients were en- couraged to attribute the cause of their headaches to relatively specific cog- nitive aberrations rather than to external stimuli or complex inner disposi- tions. Recent results suggest that the provision of such a rational cognitively oriented explanation for the client's disturbance is of therapeutic value in and of itself (Wein, Nelson, & Odom, 1975).
Following presentation of the treatment rationale, a list of stressful situations was constructed. Beginning with relatively easy situations the client and therapist focused on identifying: (1) the cues that trigger tension and anxiety; (2) how the client responds when anxious (withdrawal, attack, etc.); (3) the client's thoughts prior to becoming aware of tension, while tense and subsequently; (4) the way in which these cognitions appear to con- tribute to the client's tension and headache. The therapeutic assumption un-
126 Holroyd, Andrasik, and Westbrook
derlying these procedures is that self-monitoring will reveal cognitive dis- tortions associated with all emotional distress. It was expected that instruc- tion and practice in self-monitoring would serve: (1) to teach the client to identify or produce a cognitive component of distress, and (2) to create evidence which supports a cognitive interpretation of emotional distress. It may also turn out that the self-monitoring of cognitions will be found to operate in a manner similar to the self-monitoring of overt behavior in in- fluencing subsequent responses (Kanfer, 1971).
As soon as clients became fluent at verbalizing cognitions associated with feelings of distress they were instructed to deliberately interrupt the se- quence of covert events preceding their emotional response at the earliest possible moment. In order to do this clients were instructed to employ signs of impending distress as a signal to engage in cognitive strategies incom- patible with the further occurrence of cognitive stress responses. The strate- gies provided were designed to enable clients to employ each of the three main types of intrapsychic coping responses that have been identified by Lazarus and his co-workers (Lazarus, Averill, & Opton, 1974): cognitive re- appraisal, attention deployment, and fantasy. Specifically, clients were instructed to engage in a reappraisal of attitudes toward the distress-eliciting event ("What am I thinking to induce my distress? . . . . What are the facts?") and to emit coping self-instructions ("Calm down, concentrate on the pres- ent - there is no point in catastrophizing") or imagery ("Imagine myself for a moment carefree, at the beach"). In addition, distress-eliciting cognitions were identified as emanating from unrealistic belief systems, and clients were encouraged to suppress such cognitions because they reflected unrealistic or irrational beliefs. Clients were encouraged to implement these cognitive coping skills at the first sign of headache following the third treat- ment session.
Biofeedback Training. The rationale for this treatment emphasized that biofeedback training would enable the client to control the muscle contraction responses that generate and maintain tension headache. Auditory analogue EMG feedback from frontalis disk electrode attachments was provided for at least 30 minutes per session (Budzynski et al., 1973). The remaining time was spent in a discussion of Headache Data Cards and preparation of the apparatus. Clients were instructed to practice the relaxa- tion techniques they learned during biofeedback sessions twice daily and to employ their relaxation skills at initial signs of headache following the third treatment session.
Therapists
The two senior authors served as therapists in the stress-coping train- ing condition. The biofeedback procedure was administered by laboratory assistants. All treatments were supervised by the senior author.
Cognitive Control of Tension Headache 127
R E S U L T S
E x a m i n a t i o n o f p r e t r e a t m e n t s c o r e s p r e s e n t e d in T a b l e I r e v e a l s o c c a -
s i o n a l d i f f e r e n c e s a m o n g g r o u p s . A l t h o u g h s e p a r a t e a n a l y s e s o f v a r i a n c e
r e v e a l e d t h a t n o n e o f t h e s e d i f f e r e n c e s w e r e s i g n i f i c a n t , a n a l y s i s o f c o v a r i -
a n c e ( w i t h p r e t r e a t m e n t s c o r e s as t h e c o v a r i a t e ) w a s e m p l o y e d t o p r o v i d e
t h e m o s t a c c u r a t e a s s e s s m e n t o f t r e a t m e n t e f f ec t s .
Headache Recording
A v e r a g e w e e k l y h e a d a c h e a c t i v i t y s c o r e s a r e p r e s e n t e d in F i g u r e 1. I t
c a n b e s een t h a t t h e s t r e s s - c o p i n g t r a i n i n g g r o u p s h o w e d a m a r k e d r e d u c -
Table I. Means at Pretreatment, Posttreatment, and Follow-Up Evaluations for Major Dependent Variables
Biofeedback Stress-coping Waiting-fist training training control
Headache activity (sum) Pre 102.3 92.5 95.1 Post a 76.0 25.4 100.8 Follow-up a 74.9 21.6 95.6
Headache frequency Pre 5.7 5.3 5.7 Post a 3.7 2.5 5.0 FoUow-up a 3.1 1.6 4.7
Headache duration Pre 25.5 20.6 22.2 Post a 14.0 7.9 22.5 Follow-up a 16.7 6.1 21.2
Headache intensity Pre 3.9 4.4 4.2 Post a 3.8 2.6 4.1 Follow-up a 4.0 2.2 4.0
Psychosomatic symptoms b Pre 71.9 77.3 79.0 Post a 81.0 82.1 71.9 Follow-up a 86.7 82.2 70.5
EMG Pre 6.1 6.8 - Post a 3.3 5.3 -
Credibility c Session one 8.3 8.4 - Post 9.0 9.4 - Follow-up 9.4 9.0 -
a Adjusted means. bLarger scores represent a lower incidence of psychosomatic symptoms. CSum of two 5-point scales.
128 Holroyd, Andrasik, and Westbrook
120 (/) ~ 1 1 0 o ~100
> ' 9 0 I- > 80 1
I - ~ ro
w 6 0 "r
~ 5o
"~ 40 uJ I
3O z ~ 2o
IO
i i i i . . ~ /
I 2 Pretreatment T r e a t m e n t Posttreatment
T I M E
Fig. 1. Mean weekly headache activity scores in 2-week blocks.
i
Follow-up
tion in headache activity which was maintained at follow-up while the bio- feedback group showed more modest improvement. Wait-list control sub- jects showed essentially no improvement in headache activity.
Analysis of covariance revealed highly significant treatment effects at both posttreatment and follow-up assessments, F(2,24) = 7.7, p < .005 and F(2, 24) = 5.9, p < .01. Ttests for correlated means revealed that only the stress-coping training group showed significant improvement at posttreat- ment and follow-up assessments, t (9) = 3.3 and 3.0, respectively, both p < .01. Duncan's New Multiple Range test conducted on the adjusted posttreatment and follow-up means further revealed that the stress-coping training group differed significantly from the biofeedback and wait-list control groups, which did not differ from one another.
Pretreatment and adjusted posttreatment and follow-up means for measures of headache frequency, duration and intensity are presented in Table I. Results from separate analyses of covariance conducted on these measures revealed significant treatment effects on all three of these mea- sures (at least p < .05), with the pattern of results very similar to that re- ported for the composite headache activity score discussed above.
An examination of the data from individual subjects revealed that the superiority of stress-coping training over biofeedback appeared to result from the greater consistency in outcome produced by the former treatment.
Cognitive Control of Tension Headache 129
All subjects receiving stress-coping training reported decreases in headache activity at posttreatment, with improvement ranging from 43% to 100%. This pattern of improvement continued through follow-up. Of the 8 sub- jects who could improve (1 had reported no headaches at posttreatment), 7 continued to report further improvement in headache activity at follow-up. At follow-up, 8 of 9 subjects reported reductions in headache activity of at least 50%. Subject response to biofeedback was much more variable. At posttreatment 6 of 10 subjects reported improvement in headache activity ranging from 14% to 91°70. However, the remaining subjects reported in- creases in headache activity ranging from 10% to 154%. At follow-up 4 of the 6 subjects who reported improvement continued to improve. The re- maining 2 subjects lost part of the gains they had made during treatment. The 4 subjects reporting increases in headache activity at posttreatment re- ported even larger increases at follow-up.
Psychosomatic Symptoms
Analysis of covariance conducted on posttest and follow-up Psycho- somatic Check List scores revealed significant treatment effects present at both assessments, F (2, 24) = 8.8 and F (2, 24) = 11.7, respectively, both p < .01. Duncan's test conducted on posttest and follow-up adjusted means revealed that both the stress-coping training and the biofeedback groups reported fewer psychosomatic symptoms than wait-list control subjects (p< .05) but did not differ from one another. All subjects regularly taking medication who received treatment reported decreases in use of medication (N = 15), while equal numbers of wait-list control subjects reported in- creased and decreased use of medication, Fisher's Exact Probability Test p = .009.
Electromyographic Activity
Prior to treatment, resting levels of frontalis electromyographic activity were very similar for the three groups, F < 1. Following treatment, however, analysis of covariance revealed that subjects who received bio- feedback training showed significantly lower levels of frontalis activity than subjects who received stress coping training, F (1, 16) = 13.6, p < .002. Repeated measures analysis of variance conducted on the average EMG levels of subjects during biofeedback training revealed a highly significant reduction in EMG activity across sessions, F (1, 9) = 109.2, p < .0001. Trend analysis further revealed only the linear component of this effect to be significant, F(1, 9) = 5.5, p < .05. Thus, biofeedback training was effec-
130 Holroyd, Andrasik, and Westbrook
tive in teaching clients to effectively reduce their level of frontalis muscle activity while stress-coping training had a minimal impact on this variable. However, reductions in frontalis muscle tension were not found to be signif- icantly related to headache improvement, r (17) = .25, n.s.
Other Measures
Subjects in both treatment groups evaluated the treatment they received in highly positive terms. No differences were observed in the credibility ratings of the two treatments at pretreatment, posttreatment, or follow-up evaluations. In addition, participants in each treatment group reported they practiced the techniques they learned about three times per week between posttreatment and follow-up assessments (biofeed- back = 3.5, stress-coping training = 3.3). Correlational analysis revealed that I-E and Trait Anxiety scores as well as headache history and initial EMG level were unrelated to improvement.
DISCUSSION
The major finding of the present study was that a stress-coping train- ing procedure designed to enable individuals to identify cognitive responses to stress and to employ effective cognitive coping skills provided an effective treatment for tension headache. Thus headache sufferers receiving this treatment showed substantial reductions in headache activity that were maintained at 15-week follow-up. Since this stress-coping training proce- dure was not tailored specifically to tension headaches, but rather focused on providing general skills for coping with psychological stress, this finding raises the possibility that such procedures may prove effective in treating other stress-related psychosomatic disorders. This finding also adds to a growing body of evidence (Beck, 1976; Goldfried, Note 5; Mahoney, 1974) supporting the effectiveness of therapeutic procedures designed to alter clients' cognitions in the treatment of anxiety- and stress-related disorders.
On the other hand, the relatively poor showing of the biofeedback training procedures appears inconsistant with results from other studies (Budzynski et al., 1973; Cox et al., 1975; Haynes et al., 1975; Hutchings & Reinking, 1976). Results obtained with this treatment are particularly sur- prising in light of the considerable effectiveness of this procedure in modi- fying frontalis muscle activity. It is of note that participants receiving bio-
Cognitive Control of Tension Headache 131
feedback who showed improvements in headache activity showed smaller reductions in EMG (2.5 vs. 3.5 microvolts) and reported that they practiced the techniques they learned less often following treatment (2.5 vs. 5.0 times per week) than participants showing no improvement. Thus treatment failure did not appear to result from the failure of these participants to learn to modify their level of frontalis muscle activity or their failure to practice the techniques they learned outside the laboratory.
One obvious explanation for these results is that counterdemand instructions employed in the present study, but not in previous studies, counteracted strong implicit demands for improvement that are a necessary condition, at least for some clients, for the therapeutic effectiveness of biofeedback. The exact relationship between muscle tension and tension headache remains unclear (Bakal, 1975). Reductions in frontalis EMG during biofeedback training may account for as little as 18 % of the variance in headache improvement (Cox et al., 1975) and individuals showing low levels of frontalis muscle tension may report frequent tension headaches (Haynes et al., 1975). Such findings raise the possibility that nonspecific treatment effects associated with the impressive biofeedback training ritual, rather than specific reductions in EMG activity, account for a significant portion of the outcomes obtained with this treatment (Shapiro & Surwit, 1976; Stroebel & Glueck, 1973). Furthermore, since biofeedback-assisted relaxation training has yet to be compared with an equally credible placebo control, there exists no empirical basis for assessing the part played by such nonspecific factors in the effectiveness of this procedure.
Obtained treatment differences may have also resulted indirectly from therapist differences, although the fact that the treatments were perceived as equally impressive at all three assessments casts some doubt on this ex- planation. However, the present experimental design did not control for therapist differences, and thus does not allow this hypothesis to be elimi- nated. If subtle differences in the therapist-client relationship account for the obtained differences in outcome, this fact would also suggest that reduc- tion in EMG activity is not the major therapeutic ingredient of biofeed- back training. At any rate, given the "furor therapeutics" (Birk, 1974) that currently characterize the therapeutic application of biofeedback training, research designed to identify the part played by such nonspecific factors in the therapeutic outcomes obtained with biofeedback is urgently needed.
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132 Hoiroyd, Andrasik, and Westbrook
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