This project is funded by a grant from the National Health and Medical Research Council as follows:
Martin, P.R., & Goadsby, P.J. Should all triggers of headaches be avoided, or should headache sufferers learn to cope with some triggers? NHMRC project grant:
The most common triggers of headaches are: stress and negative emotions; sensory triggers (flicker, glare, eyestrain, noise, odours); hunger; lack of sleep or excess of sleep; food and drink; alcohol; menstruation; and weather. The standard clinical advice is that the best way to prevent headaches is to avoid the trigger factors. Although the logic of this advice is clear, there are a number of problems with it. It is not possible to avoid all triggers and attempts to do so may prove stressful and lead to a restricted lifestyle. The advice is given in a conceptual vacuum in the sense that it is not based on a theory of how a trigger acquires the capacity to precipitate a headache or how that capacity can be extinguished, and therefore what effect this advice may have on the potency of the trigger factor. Finally, the empirical support for advising avoidance is very limited.
Consideration of congruent literatures raises questions about the wisdom of advising avoidance of all headache triggers. Avoidance is considered to not be an adaptive way of coping with stress, with a few exceptions, and exposure to less threatening stressful events is a component of some successful stress management programs (e.g., stress inoculation training). ‘Experiential avoidance’, a form of avoidant coping, is associated with higher levels of general psychopathology, anxiety, depression and lower quality of life. Treatment techniques that change experiential avoidance have achieved positive outcomes on a range of measures. In the anxiety literature, avoidance of anxiety-eliciting situations is considered to underlie the maintenance of anxiety disorders, whilst exposure-based treatment approaches are highly effective.
Research on headache triggers driven by the anxiety literature has shown that short exposure to a range of headache triggers – visual disturbance (flicker, glare, eyestrain), noise, and stress – is associated with sensitisation to the trigger, whilst long exposure is associated with desensitisation. Repeated prolonged exposure to visual disturbance has been shown to lead to desensitisation (increased tolerance) – that is, the trigger losing the capacity to precipitate headaches.
The MaTCH research is a randomised control trial with four conditions: avoidance of triggers (‘avoidance’); avoidance of triggers plus CBT (‘avoidance + CBT’); coping with triggers (‘coping’); and waiting-list control condition (‘WL’). It is predicted that ‘avoidance’ will lead to fewer headaches at post-treatment than ‘WL’. At follow-up, the headaches of participants in this group will have returned to around baseline levels due to any positive effects being cancelled out by sensitisation to some triggers. ‘Avoidance + CBT’ should be associated with superior results to ‘avoidance’ both at post-treatment and at follow-up, due to the addition of CBT. ‘Coping’ should be superior to ‘avoidance’ and equivalent to ‘avoidance + CBT’ at post-treatment, and superior to both at follow-up due to sensitisation occurring in the two avoidance conditions. The superiority of the ‘coping’ condition in the long-term will also manifest on other variables, specifically quality of life measures, as participants in this condition will have a less restricted lifestyle, and greater self-efficacy and a more internal locus of control for managing headaches. It is also predicted that ‘coping’ will be associated with a reduction in the number of factors that can precipitate a headache, which will not be the case for the avoidance interventions. The study will include 180 adults diagnosed as migraine and tension-type headache, recruited from the general public.
The ‘coping’ intervention will consist of using exposure to headache triggers except where this is not possible or would seem inappropriate; together with relaxation and cognitive techniques for challenging dysfunctional thoughts and beliefs, to facilitate exposure. Exposure is most likely to be used with the triggers of stress and negative emotions, and sensory triggers. Avoidance is most likely to be used with the triggers of hunger and lack of, or excessive, sleep. Longer rather than shorter exposure will be used, but exposure that falls short of inducing significant headaches.
This will be the first controlled trial of the standard clinical advice to avoid headache triggers. Such a trial is long overdue, particularly as there is a plausible argument that the advice to avoid may be counter to the interests of headache sufferers as it could lead to decreased tolerance of triggers and therefore more headaches. It will also evaluate a coping approach to triggers that should prove more effective. The outcome of this research should lead to better management of headache disorders with all the advantages this has in terms of reducing suffering and costs.
Recruitment for The MaTCH Project is now complete. The team would like to thank all those that have supported our research.