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The purpose of this review is to summarize the role of avoidance behavior in headache-related disability and overview relevant clinical implications. Avoidance occupies a central role in contemporary psychological perspectives on headache disorders and other chronic pain conditions. Several cognitive constructs of relevance to headache are influenced and maintained by avoidance behavior. A growing body of literature attests to the notion that avoidance of headache triggers, of stimuli that exacerbate headache, and of broader life domains can negatively affect headache progression, disability/quality of life, and comorbid psychiatric symptoms. Interventions targeting avoidance behavior, such as therapeutic exposure to headache triggers, mindfulness, and acceptance and commitment therapy (ACT), hold promise for headache disorders but need to be tested in larger trials. Researchers and clinicians are encouraged to attend to functional impairment as a critically important treatment outcome. Comprehensive understanding of headache disorders necessitates attention not merely to diagnostic symptoms and their reduction, but to patterns of avoidance behavior that inadvertently exacerbate headache and contribute to functional impairment.

Despite emerging evidence for the comorbidity of posttraumatic stress disorder (PTSD) and migraine, few studies have examined the relation of PTSD and migraine, particularly among clinical populations at-risk for both conditions (e.g., substance-dependent patients). This study examined the role of PTSD symptoms in migraine and headache-related disability within a sample of 153 substance-dependent inpatients (37.25% female, Mean age 36.46). PTSD symptoms predicted both migraine and headache-related disability above and beyond gender, depression and anxiety symptoms, the experience of a Criterion A traumatic event, and current alcohol use disorder. Findings highlight the strong association between migraine and PTSD symptoms in a unique population at risk for both conditions.

Background This research sought to further validate the rat nitroglycerin (NTG) migraine model by comparing the effects of single versus recurrent NTG episodes on behavioral endpoints that mirror ICHD-3 diagnostic criteria for migraine, and to determine if the altered behavioral endpoints are reduced after administration of sumatriptan. Methods Separate cohorts of rats were administered NTG (10 mg/kg/2 ml) or saline (Experiment 1: single injection; Experiment 2: repeated injections; Experiment 3: repeated injections with sumatriptan [0.0, 0.3 and 1.0 mg/kg/ml] rescue. Behavioral endpoints were assessed 2 h after final NTG administration and included time in light/dark chambers for photophobia and activity, pain facial ratings, and cool (5 °C) and warm (46 °C) tail dip. Results The first two experiments demonstrated that repeated (n = 5) but not single NTG injections produced photophobia, decreased activity, and yielded less weight gain than saline injections. Experiment 3 showed that sumatriptan attenuated hypoactivity, reduced facial expressions of pain, and reversed weight alterations in a dose-dependent manner. Conclusions These findings identify numerous clinical homologies of a recurrent NTG rat migraine model that may be useful for screening novel pharmacotherapies.

Migraine is often comorbid with depression. Although much of the research on migraine and depression is of an epidemiologic nature, there is an emerging appreciation of clinical issues and the need to adequately treat depression in migraine sufferers. The present article reviews traditional pharmacological and psychological treatments for depression, with special emphasis on migraine patients. It then reviews the evidence base for some of the complementary and alternative treatments for depression that are very popular in both Europe and the United States.

A growing body of literature has implicated comorbid psychopathology as a potential risk factor for the chronification of migraine. Of the psychiatric disorders, depressive and anxiety disorders have been most consistently associated with the chronification of migraine. A shared dysfunction of the serotonergic system, medication overuse, and psychological factors have been proposed to mediate this relationship, although the responsible mechanisms are still largely unclear. This article overviews literature on psychiatric comorbidities and migraine chronification, considers mechanisms underlying this relationship, and notes directions for future clinical and empirical work.

Migraine is often comorbid with psychiatric disorders such as major depression, bipolar disorder, and anxiety disorders. Although most of the research on psychiatric comorbidities and migraine is of an epidemiologic nature, a growing body of literature has investigated possible mechanisms underlying this relationship, such as medication overuse, serotonergic dysfunction, ovarian hormone fluctuations, and central sensitization. The present article overviews this growing literature and notes strategies for the clinical management of migraine patients with psychiatric comorbidities.

Comorbid psychopathology has been implicated as a risk factor for the chronification and progression of migraine. Although past research has focused principally on depression and migraine, recent research consistently has confirmed that a disproportionate number of migraineurs suffer from one or more comorbid anxiety disorders. Moreover, this research has implicated anxiety disorders as factors potentially associated with migraine intractability and progression; growing evidence suggests that anxiety disorders may be even more prognostically significant than depression. This article summarizes these recent developments, considers mechanisms underlying this comorbidity, discusses strategies for assessing and managing comorbid anxiety, and notes directions for future clinical and empiric work.

Although the efficacy of behavioral interventions for migraine (e.g., relaxation training, stress management, cognitive-behavioral therapy, biofeedback) is well established, other behavioral interventions that have shown efficacy for other conditions are being adapted to treat migraine. This paper reviews the literature to date on acceptance and commitment therapy (ACT), mindfulness-based interventions, and behavioral interventions for common migraine comorbidities. ACT and mindfulness interventions prioritize the outcome of improved functioning above headache reduction and have demonstrated efficacy for chronic pain broadly. These emerging behavioral therapies show considerable promise for improving outcomes of migraine patients, particularly in reducing headache-related disability and affective distress, but efficacy to date is limited by small trials, short follow-up periods, and a need for comparison or integration with established pharmacologic and behavioral migraine treatments.

Trends in anxiety assessment were established by examining the methods reported in anxiety-related papers published in three prominent behavior therapy journals from 1970 to 2002. Assessment methods were categorized using Lang's three-system concept of anxiety (P. J. Lang, 1968) as an organizational framework. Analysis of the research methods suggests two primary patterns. First, multisystem assessment declined in the last several years by comparison with previous years whereas the assessment of a single response system (typically self-report) has increased. Second, among anxiety-related papers reporting multimodal assessment, physiological assessment returned to 1970s-era frequency in recent years after an upsurge in the mid-1980s and early 1990s. Some possible interpretations and implications of these trends are discussed.

This review describes empirical evidence for a bidirectional relationship between tension-type headache (TTH) and sleep. In its most severe form, chronic TTH (CTTH) affects 2-3 % of the population and can be very disabling. Sleep dysregulation triggers episodic TTH, and sleep disorders may complicate and exacerbate headache. The majority of CTTH sufferers also have insomnia, and longitudinal data suggest that insomnia is a risk factor for new-onset TTH. Similarly, observational studies suggest that sleep disturbance is a risk factor for new-onset TTH and for progression from episodic to chronic TTH (i.e., headache "chronification"). CTTH is the most common headache secondary to sleep apnea and other sleep-related breathing disorders. Psychiatric disorders are comorbid with both TTH and insomnia and may further complicate diagnosis and treatment. Developments in diagnostic classification of sleep-related headache are presented.