HEADACHE: behavioural therapy

“I’m very brave generally,” he went on in a low voice:


“only today I happen to have a headache.”


-Lewis Carroll



Being at ease with not knowing is crucial for answer to come to you.

-Eckhart Tolle



  • A Functional Model implies that it works to get you where you want, without knowing for certain exactly how it works. 

    • This is not foreign to us: Most of us drive every day without knowing how a car works.
    • So, in this model, we are concerning ourselves with getting you to function the way you would like to function
    • The experience of a headache changes depending on the circumstances
    • We will acquire skills and change your lifestyle in ways that is associated with positive change


  • The best way to get the data you need to is observe your own headache.

    • To observe your own headache, you have to observe the environment in which it grows, that is, within the context of the biopsychosocial model.
    • Stress and negative emotions remain the most influential factors on headaches


Stress is a condition or feeling experienced when a person perceives that “demands exceed the personal and social resources the individual is able to mobilize.”

-Richard Lazurus


  • To highlight the kinds of questions we concern ourselves with in a functional model, consider the following:

    • Yesterday morning, why did you get a headache rather than the day before?
    • Why are they lingering now for you, and not for others?
    • Or now, and not at another time in your life?


  • Well, don’t certain types of headaches need certain kinds of treatments?

    • Certain medications have evidence in certain conditions.
    • Interestingly, most prophylactic medications for migraine were originally intended for other conditions:
      • antidepressants
      • anti-hypertensives
      • anti-convulsants
      • anti-inflammatories, etc.
    • However, the neurophysiological evidence that the mechanisms between different types headaches are really different is a bit limited.
    • And the evidence that they respond differently to behavioral treatment is limited.


What about for Post-traumatic headache?

    • Medication typically used for acute and preventative migraine treatment has poor treatment efficacy in PTH, further suggesting the differential pathophysiology of PTH versus migraine, despite phenotypic similarities (Ashina et al., 2020).
    • There are no clear guidelines on how to treat posttraumatic headache (PTH) or post-concussive symptoms (PCS). However, behavioral interventions such as cognitive behavioral therapy, biofeedback, and relaxation are Level-A evidence- based treatments for headache prevention (Minen et al., 2019).
    • Despite headache being common after mTBI, there is little research in a postinjury population to guide medication management and decisions are largely based on clinical experience. Finding effective treatment is important to optimize quality of life as those with persistent headache may have higher levels of disability and a less active lifestyle than prior to injury (Marcus, 2003).

“How you look at it is pretty much how you’ll see it.”

-Rasheed Ogunlaru



  • So, how should we look at a headache and its environment?

    • Here we use the model put forth by Dr. Paul Martin.


  • We want to observe the fertile soil of a headache, the blooming of the headache and the fruit given off by the headache.

    • That is, to investigate our headaches, what happened/what did we do/what did others do:
      1. Just before the headache? ANTECEDENTS
      2. During the headache? HEADACHE PHENOMENA
      3. After the headache? CONSEQUENCES

Antecedents are factors that are around in your life before any specific headache starts.

As per Dr. Paul Martin, there are four categories of antecedents:



  • These are things considered to be part of your personality, which is said to be mostly inherited. These can be factors like:
  1. Type A personality/behaviour style
  2. Perfectionism, rigidity, need for control
  3. Low self-esteem, self-confidence, assertiveness
  4. High trait anxiety, anger, depression
  • Note: Majority of “Type A” people don’t have headaches, and not all headache-sufferers are “Type A”; but there may be more Type A people in the headache population than in the non-headache population
  • These factors can be trained by various forms of psychotherapy.



  • These refer to factors that arose when the problem with headaches started.
  • While we can’t do much about the past, this is included in the model because patients and doctors want to acknowledge the even, e.g., concussion, that caused the headache.
  • Onset antecedents May have no significance for the maintenance of the problem.
  • However,  the reasons behind going from concussion to Post-concussion syndrome is not entirely known
  • Resilience model suggests that those who had gone through a lot, or who had been going through a lot prior to the injury may be more prone
    • Among the 165 participants who were deemed positive for a history of mTBI during a primary care visit, a cumulative measure of adversity was positively associated with post-concussion and traumatic stress scores, whereas resilience scores were negatively associated with these outcomes (Reid et al., 2018).
  • Going through challenges sometimes leads to maladaptive beliefs that are either reinforced or develop in the face of the concussion.
  • These factors can be trained by various forms of psychotherapy.



a) Stress:

  • Stress management techniques aimed at stressful factors in patients’ lives are likely to play a positive role in all.
  • The treatment usually focuses on the sources of stress (e.g., child management training, marital therapy, family therapy, assertion training, social skills training, vocational counseling) and can use many techniques (e.g., Solution-Focused Brief Therapy, cognitive behavioural therapy, emotionally focused therapy, mindfulness, etc.)
  • Increasing perceived social support

b) Negative emotions

  • These can be things like anxiety, anger and depression that are in your life right now.
  • These can be dealt with in other programs like CBT, Resilience training, psychotherapy, mindfulness, positive psychology, goal-oriented therapy, etc.

c) Lifestyle or life situation factors

  • Lack of: regular routines, engaging in leisure activities, and regular exercise, etc.
  • Marital problems, difficulty managing children, financial difficulty, lack of fulfillment in life, social isolation, etc.
  • Don’t give the idea that the headaches are an inevitable response to certain life circumstances
  • Note: Majority of people with these stressors don’t have headaches, and not all headache-sufferers will have these issues; but there may be more of these issues at play in the headache population than in the non-headache population.
  • Treatment revolves around setting healthy lifestyle habits using various strategies like cognitive, psychological and behavioural interventions.

d) Other related problems

  • These can be other things going on that are associated with headaches, factors like:
    • Insomnia
    • Sleep apnea
    • chronic neck pain
    • overweight
    • medication causing headaches
  • Focus is placed on how you view these factors, or coping with these factors, in a way that is good for you
  • These can also be remedied by, for example, CBT-i, exercise and diet, etc.



  • These refer to triggers that you have identified as being correlated with your headaches
  • usually things that occur within minutes to hours before your headaches
  • These can be things like:
    1. Stress & negative feelings like anxiety, anger, depression, etc.
    2. Sensory stimulation like loud noises, background noise, flicker, glare, eyestrain, visually rich areas, fluorescent lighting, screens, etc.
    3. Diet: fasting, alcohol, certain foods, etc.
    4. Weather: high humidity, high temperature, changes in weather, etc.
    5. Hormones: luteal phase of the menstrual cycle, etc.
  • Learning to manage triggers in an effective way is an art. Approach behaviours are ideal (as opposed to endurance or avoidance behaviours, read more here.)

What fires together

Wires together



This refers to the ability to regulate your physiology just with mindfulness and intention.

This is often trained using biofeedback modalities.



How do you experience your headache?

Using relaxation and cognitive strategies like visual imagery and attention-diversion, we can change the experience of the headache.

The more we practice changing the experience, the more the experience changes.



  • Most patients respond to headaches in ways that create vicious cycles by exacerbating antecedent factors of the headache experience itself.
    • Interestingly, the same is true with knee injuries, back injuries, ankle injuries, etc.
    • Most of us tend to adopt ways of moving and thinking that actually makes these injuries worse.
    • E.g., if you become tense, frustrated or anxious a vicious cycle between these emotions and headache can occur
    • E.g., if you get angry with partners, it can provoke retaliation in the short-term and marital discord in the long run
  • Becoming distressed by a headache is a normal reaction but it will increase the likelihood of more headaches


  • Sometimes, those who are close to you, although they mean well, may respond to you in ways that increase your stress, either by lack of support, or “too much help”
  • The way others respond to your headaches will affect the headache experience and the likelihood of future headaches occurring.



  • These can refer to consequences that result from chronic headache, things like decreased social and recreational hobbies, low level of social support, depression, marital problems, financial problems, less exercise, etc.
  • This can cause patients to develop low self-esteem or an external locus of control.
  • As you can see, the long-term consequences of chronic headaches can set up a vicious cycle between consequences and antecedents.
  • Usually, consequences are a reflection of antecedents and headache factors, so, positive consequences can be seen as a barometer of effective interventions at the antecedents and headache phase of the functional model of chronic headache.



Check out our worksheet.


Evaluate the factors in your life that are correlated with your headaches.


Use the questions in the next section to help you in filling out each column.


You will find that each factor has certain questions to help you identify the right factors to enter in its corresponding columns.


An example of how a completed worksheet looks can be seen in the last tab.




Before having chronic headaches, did you believe any of the following were part of your personality?

  1. Type A personality
  2. Perfectionism, rigidity, need for control
  3. Low self-esteem, low self-confidence
  4. Passive, aggressive, or passive-aggressive behaviours?
  5. Anxiety
  6. Depression
  7. Anger



  1. What happened for your headaches to begin?
  2. What others challenges were going on in your life just before the start of your headaches?
  3. What was your attitude towards those challenges and life in general before the start of your headaches?
  4. How has your attitude changed as a result of the onset factors for your headache?



i. Stress

  1. Which stressor in your life right now would you like to manage better?
  2. Which specific strategies are you using in helping you to achieve better stressor management?
  3. What support do you believe you could use to reduce your stress?

ii. Negative Emotions

  1. How would you like your general emotional state to be different?
  2. What have you done to try to achieve this?

iii. Lifestyle/Life Situation

  1. Say the effect of headaches on your life were not present, what difference would that make to your general daily schedule and the activities you participate in?
  2. What are some activities that used to bring you joy that you would like to see yourself doing again?

iv. Other Related Problems

  1. What sorts of things are going on with your health that you have correlated with your headaches (e.g., sleep difficulty, overweight, depression, neck pain, driving, etc.)?
  2. What are you doing to improve them?



  1. Which triggers have you identified to be correlated with your headaches?
  2. On a scale of 0-10 (10 being most likely), how likely are you to:
    • Avoid the trigger?
    • Confront the trigger?







i. When you get a headache…

  1. How would you like your emotional state to be different?
  2. How would you like your train of thought/attitude to be different?
  3. Which strategies do you employ to improve your situation?

ii. On a scale of 0-10 (10 being the highest), what is your level of confidence that:

  1. you will be able to cope with a task at hand despite having headache?
  2. You will be able to take measures to control the likelihood that you get a headache?

iii. Regarding relaxation practices:

  1. Which practices do you currently do?
  2. How often do you do them?
  3. What benefit do they provide?






i. Immediate consequences of the headache that affects how you relate to yourself.

Times when you believe that there is the possibility of coming down with a headache, or when you feel the start of a headache, how would you like the following to be different than they are right now?

      1. Your thoughts?
      2. Your emotions?
      3. What you do (behaviours)?
      4. Interactions with others?

ii. Immediate consequences of the headache that affects how others relate to you.

How do you perceive how others respond to you when:

    1. You have a headache?
    2. You don’t have a headache?



i. Long-term consequences on your life.

Which general areas in your life would you like to see better as a result of improving the way you manage your headaches?

ii. Long-term consequences on the lives of those close to you.

How would you like your relationships with those close to you be better as a result of improving the way you manage your headaches?

Ashina H, Iljazi A, Al-Khazali HM, et al. Persistent post-traumatic headache attributed to mild traumatic brain injury: Deep phenotyping and treatment patterns. Cephalalgia. 2020;0(0):1-11. doi:10.1177/0333102420909865
Marcus D. Disability and chronic posttraumatic headache. Headache. 2003;43:117-121.
Martin, P. (1993). Psychological Management of Chronic Headaches: Treatment Manual for Practitioners. Guilford Press.
Minen M, Jinich S, Vallespir Ellett G. Behavioral Therapies and Mind-Body Interventions for Posttraumatic Headache and Post-Concussive Symptoms: A Systematic Review. Headache. 2019;59(2):151-163. doi:10.1111/head.13455
Reid MW, Cooper DB, Lu LH, Iverson GL, Kennedy JE. Adversity and Resilience Are Associated with Outcome after Mild Traumatic Brain Injury in Military Service Members. J Neurotrauma. 2018 May 15;35(10):1146-1155. doi: 10.1089/neu.2017.5424. Epub 2018 Mar 16. PMID: 29357779.

Last update: March 2021