HEADACHE: problematic reactions

Reinforcement refers to the notion that there may be secondary gains (i.e., a silver lining) to the experience of headaches, often without our conscious awareness of the same.

 

THE ELEPHANT IN THE ROOM

• We are aware that this is often seen as an uncomfortable and unpopular topic.

 

• Some may take it to imply that their headaches aren’t genuine, but rather, a ploy to gain some sort of reward, or fulfill some sort of hidden agenda.

 

• This is not the case
  • We are all molded by our environments to some extent, usually without our awareness.
  • Becoming aware of these factors so that we can influence them in a way that sees us being more successful is a worthwhile endeavour.

 

• To add to this topics unpopularity, it is difficult to assess for reinforcement mechanisms.
  • The hope is an awareness of the forces that have been found to influence headaches can modify our behaviours so that they are adaptive:
    • reducing the headaches’ reinforcement mechanisms (i.e., the headaches’ “backers”)
    • and improving our quality of life

 

An analogy:

The youngest in a family of 5 may have learned that the best way to get what they want is to have a low threshold to cry and get mom and dad’s attention, rather than being assertive with their older siblings. Mom and dad may swoop in and defend the young child and punish the older siblings. This child may learn that temper tantrums and negative emotions, or other “slippery” ways of getting what they want are effective. If these negative emotions were to run amuck and result in depression or anxiety, when would this child notice that this approach to getting what they want may be holding them back?

 

RESEARCH SUGGESTING THAT THERE COULD BE THINGS IN OUR LIVES THAT REINFORCE HAVING HEADACHES

• Headaches are a socially acceptable sign of distress that can be used for eliciting a show of concern and affection from family, friends and physicians (Martin, M.J., 1983).
• Some patients learn early in their headache history that they can escape their responsibilities and often literally control their environment (Martin, 1966).
• Some authors have suggested that reinforcement for headache complaints is only likely to be of significance for a small minority of headache sufferers (Holroyd & Andrasik, 1982; Haynes, 1981).
• Migraine sufferers (when compared to headache-free people) were more likely to describe their families as (Ehde, Holm & Metzger, 1991):
  • Emphasizing clear organization, structure, rules and overall control
  • Less likely to encourage emotional expression
  • Hypothesis: pain behaviours may be reinforced in these families as acceptable ways to express emotional distress.
  • Data shows that partners generally tend to react to patient’s headaches in supportive ways.

 

• What are the most stereotypical ways headache patients and their partners respond to the patient’s headaches (Martin, Milech & Nathan, 1992)?
  • Headache patients most commonly respond to headache by:
    • Stopping what they were doing and sitting/lying down;
    • Taking medication
  • Partners tend to respond to how severe they perceive the patient’s pain is (Flor, Kerns & Turk, 1987)
  • Partners most commonly respond to the patient’s headache by:
    • Offering sympathy
    • Getting medication
    • Encouraging sufferers to stop what they were doing and sit/lie down
    • Encouraging patients to “plow through” or ignore their headaches was a rare occurrence
  • Patients can mold their partners to respond in a way of their choosing (i.e., synchrony):
    • E.g., if a patient tends to respond to their headache by eating or drinking, the partner tended to respond to the patient’s headache by bringing the patient food and drink.

There are some definitions we would like to get out of the way.

 

Positive reinforcer

• Any event, behaviour, privilege or object that increases the probability of headaches recurring
• e.g., possibly spousal reassurance and consolation, getting medication for yourself/someone getting medication for you

 

Negative reinforcer

• Any event, behaviour, privilege or object that when withdrawn, increase the probability of headaches recurring
• e.g., possibly getting out of a stressful work or family situations

 

• The word “possibly” is used, because it’s only possible that an event is a reinforcer if we can observe that the suspected reinforcer actually affects the patient’s behaviour.

 

Social Unresponsiveness

• When partners or family do not respond in the way the patient is seeking for immediate gratification.
• This does not imply ignoring the patient.
• E.g.,
  • Patient: I’m so stressed, I’m going to lie down before I get a headache
  • Partner: I was about to go for a walk, come join me?
    • rather than something like, “oh, honey, can I get you anything before I tuck you in?” or “don’t lie down, it’s not good for you because the doctor said so”

 

Punishment

• This is generally not used in Contingency Management Programs for headaches.

 

Schedules of reinforcement

• This is sort of an algorithm that states under which circumstances certain Contingency Management Procedures will be executed.
• E.g.,
  • Whenever a green light headache is present…
    • partners will be socially unresponsive to complaints of headaches.
    • the patient will carry on business as usual that is in keeping with their goals.
  • Whenever a yellow light headache is present…
    • the patient will stop what they are doing but rather than sitting or lying down, they will do relaxation exercises or practise some other attentional diversion technique.
    • And before deciding to take medication, they will fill out an Advantages-Disadvantages Analysis Worksheet about the options they are considering on taking in the face of their headache.
    • Partners may encourage the patient to limit screen time and participate in relaxation strategies, Heart Rate Variability training, going for a walk, etc.

 

Shaping

• To shape one’s behaviour, you have to have a clear picture of the patient’s desired behaviour.
• Then, the closer the patient’s behaviour gets to looking like the desired behaviour, they get positive feedback/reinforcement for that.
• Whenever their behaviour is further away from the goal they want to reach, those behaviours are not reinforced.
• E.g., take the situation where a patient would like to participate in their daily Home Exercise Program which includes a walk and measuring their heart rate as prescribed, but have only been doing it thrice a week:
  • steps they take to going for their walk are encouraged and applauded – even if it is just putting on their shoes and going around the block as it would be a step closer to 7 days a week of exercise.
  • skipping a workout could be faced with social unresponsiveness.

 

Extinction

• This is kind of like when someone gets braces, and the braces stay on for much longer than when the teeth have been finally straightened.
• Like that, once you stop reinforcing desirable behaviours (or start responding to negative behaviours), the patient can drift back to old ways that didn’t suit them well.

 

Generalization

• This is when the patient learns to deal with new/different stresses (different than those included in the reinforcement schedule) and challenges adaptively, i.e., more in line with their desired outcome.

Can those around you discriminate between headache and headache-free states?

 

Do you let everyone know you have a headache? Or are there subtle tells like facial expression changes?

 

Did you answer “no”?

• Is it truly a “no”?
• Or, did you say “no” because you felt that’s what you should have said because you don’t want to burden others?
• If you your “no” is accurate, then there is no opportunity for social reinforcement.

 

Again, this is a tricky area to assess, but we present it here because these factors do influence headache and your awareness of these factors may improve your headaches.

 

Even if those around you can tell when you are having a headache, it is difficult to evaluate what constitutes a reinforcer.

• Example: negative emotions by a spouse such as being angry or frustrated at your headache
  • may cause you to appreciate their loyalty, or at least their attention on your problem.
  • Or, it’s even possible that the patient may like to cause their spouse this distress.
  • However, just because these things happen, this doesn’t necessarily mean that the headache are being reinforced by them.

 

• If someone’s response to the patient and their headache is highly variable, it’s unlikely that it is a reinforcer
  • There has to be some – not necessarily absolute – consistency to make the event, behaviour, privilege or object a plausible reinforcer.

 

To tell those around you that you have a headache, or to not tell?

• What are the advantages of telling? The disadvantages of telling? The advantages of not telling? the disadvantages of not telling?
  • Have a look at our “Advantages-Disadvantages Analysis Worksheet” to work it out for your situation

 

• Extreme example 1: you never tell anyone

  • If others don’t know when you have a headache, they can’t help or support you

 

• Extreme example 2: you tell everyone

  • people may react negatively towards you if they see you as complaining

• If you have identified the reactions (to headaches) that increase headache and its consequences, then we can develop a plan of action to curb our problematic reactions to headaches.

 

This is called a Contingency Plan.

 

• Check out the Traffic Light Approach to Contingency Management Worksheet.

 

• You will remember that it is challenging to identify reinforcement mechanisms.

 

• It is also challenging to develop contingency management programs for headache patients.

 

• Typically, for other conditions (e.g., addictions, lower back pain), Contingency Management Programs require control of the patient’s environment.

 

• • This is not feasible for headache patients as most are not generally disabled enough to justify extended stays in institutions.

 

• • This means that Contingency Management Programs must be implemented by training relatives
    • …Therein lies the rub.

The main Principal:

To minimize the reinforcement of pain behaviour

while maximizing the reinforcement of well behaviour.

 

In headache patients, this would look something like:

• Relatives encouraging headache patients to not avoid things out of fear that that will trigger a headache, even when there is weak or no evidence that is the case.

• • E.g.,
    • A patient may fear that going for a walk may trigger a headache because they had a headache during the last walk they went on.
    • A spouse may point out that several times before that they went on a walk without triggering a headache or making their headache worse, and encourage them to go on a headache using their own skills in persuasion.

 

• Relatives encouraging patients to cope in adaptive (i.e., desirable ways)

• • Example 1
    • Avoiding a concert may be a good idea.
    • Likewise, lying down during a severe headache may also be a good idea and could be encouraged by family.

• • Example 2
    • Lying down in the face of the stress of doing your taxes because of fear of triggering a headache would not generally be the best way of coping.
    • A more adaptive way may be for relatives to encourage relaxation strategies and imagery techniques for example.
    • Or to highlight other times they have overcome obstacles by leveraging their strengths, or a particular approach (e.g., pacing, breaking it down into smaller steps, etc.)

The principal hurdle revolves around judiciously knowing when and when not to carry out Contingency Management Procedures:

 

• For example, when should we exercise extinction procedures for pain behaviour requires some thought.

 

• • Example 1
    • preventing patients from telling others about their headaches may not be a good idea;
    • asking for help can be a desirable response to headache.

 

• • Example 2
    • encouraging a headache patient’s spouse to be “socially unresponsive” can be inappropriate in some contexts, i.e., during a severe migraine.

 

• • Example 3
    • if mild headaches are consistently followed by negative reinforcement (e.g., letting people off from having to do things they don’t want to do), then changing (i.e., making more difficult) how comfortable it is for them to get out of it seems appropriate.

• This should be collaborative between patients and their family, respecting each other’s sensitivities, and should be steeped in goodwill and improving the patients’ headaches.

 

• Remember:

  • both parties’ responses have been shaped over long periods of time.
  • Some things may seem difficult, e.g., for a spouse to be “socially unresponsive” when their partner is experiencing some pain.

 

• This could involve how relatives respond to the patient in different situations.

  • We suggest the Traffic Light Approach to Contingency Management Worksheet.

 

• The overall level of reinforcement should not decline.

• • If reinforcement is being withdrawn for certain types of pain behaviour, it should be increased for more adaptive, coping behaviour.

• • Positive reinforcement (for adaptive coping behaviour) + negative reinforcement (for maladaptive pain behaviour) = remains constant

• • • e.g., Sometimes headache patients only get support from their family when they get a headache, so there is a danger that reducing reinforcement for pain behaviour will leave them with no support at all.

We have discussed what constitutes avoidance behaviour in another article “Behaviours Associated with Longer Recovery“.

There is evidence that avoidance behaviour plays a role in maintaining chronic pain via (Philips 1987a):

 

• Increased sensitivity to pain-inducing stimuli (e.g., ambient lighting) in the short-term

 

• Adversely affecting self-efficacy beliefs relating to pain in the long-term

• • Self-efficacy is a person’s belief in their ability to succeed in a particular situation. Bandura described these beliefs as determinants of how people think, behave, and feel (Bandura, 1997)

• • The more chronic headaches we have, the more avoidance behaviours we exercise, and the less control we believe we have over getting on with life in the face of headaches.

 

• Through negative reinforcement mechanisms

• • i.e., reinforcement of “invalid status” as avoiding doing things when you have a headache often feels easier in the short-term than doing something, even if it’s something different than what you were doing when the headache started, or started getting worse

Research by Philips & Jahanshahi (1986) lead to the following observations:

• The most common avoidance behaviour is social avoidance or withdrawal
• High avoidance was associated with elevated depression

 

In another study by the same authors (Philips & Jahanshahi, 1985), chronic headache patients were exposed to loud noises, they hypothesized that:

 

1. exposure to a salient pain-provoking stimulus would lead to increased tolerance by a process of adaptation
2. Avoiding the stimulus would increase the potency of such stimuli to provoke pain.

 

Results tallied with the hypothesis:

 

1. exposure under conditions of relaxation was effective in reducing pain behaviour
2. avoidance of exposure to this noise led to increasing intolerance.

On the one hand,

• anyone who has had a severe headache (e.g., “red light” headache) knows that quitting what you’re doing may be the most adaptive thing to do.

 

On the other hand,

• chronic headache patients tend to overreact and respond in ways that are not necessary.

 

Patients should consider alternative things they can do in the face of a headache,

• perhaps by brainstorming and then completing an Advantages-Disadvantage Analysis Worksheet with respect to the choices.

 

Often Behavioural Experiments are required to create new Core Beliefs.

There are many possible antecedents (or triggers) for headaches.

 

• Stress and negative emotions have been identified as been the most common triggers for headache;

• • this has been discussed in our article “Headache: Psychology “.

 

Chronic headache patients, in response to their headaches, often entertain maladaptive thoughts & emotions that actually feed into the headache–stress & negative emotions vicious cycle discussed in the article Headache: Psychology”.

 

STRESS & NEGATIVE EMOTIONS ⇔ HEADACHE

 

With the exception of one (positive coping), six of seven identified thought clusters are negative (Philips, 1989):

1. Desire to withdraw
2. Disappointment with self
3. Causal rumination
4. Helplessness
5. Concern with effects of pain
6. Emotional reactivity

 

Another study found the following maladaptive thoughts & negative emotions (Penzien, Holroyd, Holm & Hursey, 1985):

1. Nonproductive rumination
2. Self-criticism
3. Irritation over environmental difficulties,
4. tension or worry

 

Relating cognitively to the headache in a more adaptive way can check the headache–stress & negative emotions vicious cycle.

 

STRESS & NEGATIVE EMOTIONS ⇔ HEADACHE

In addition to reactions as headaches as stressors (as described above in the section “Reactions that add to your stress and negative emotion”), there are other ways that patients can respond to headaches that increase the likelihood of more headaches.

 

Example

• When a headache is over, a patient may overwork and do a flurry of activities (i.e., “revenge work/tasks”) in fear that this is the only shot they have to get it done before the next headache.
• This lack of lifestyle balance can bring about more headaches and ironically reduce the patient’s quality of life, rather than increase it.

There are some factors that heighten pain perception:

 

1. Anxiety and catastrophizing

 

2. Focusing attention on painful experiences

1. • Demjen et al. (1990) observed that headache patients shift from focusing on their lives (situational and interpersonal issues) to focusing on their headaches.

 

3. Believing that you have no control over the pain (whether you do have control over the pain or not)

1. • This was discussed in this article in the section on “Avoidance Behaviour”

Patients often resort to medication in the face of a headache.

• Often this is an adaptive behaviour.
• It has been suggested that sometimes, over-reliance on medication can cause more headaches.
  • This is a medical diagnosis known as Medication Overuse Headache.

 

There is some debate over whether MOH truly exists

• with the majority of physician’s subscribing to its existence.

 

However, in a functional headache model, resolving this dilemma is not the principal focus

• Rather, to put it simply, the focus is on right-sizing the role medication plays in headache management relative to the strategies outline in our article “Headache Behavioural Therapy”.
• By engaging in life in a way that is more adaptive, employing may behavioural and psychological strategies and skills, medication use usually decreases.

 

More information will be provided on MOH in a future article.

Bandura A. Self-Efficacy in Changing Societies. Cambridge University Press; 1997.

Demjen S, Bakal DA, Dunn BE. Cognitive correlates of headache intensity and duration. Headache. 1990;30(7):423-427. doi:10.1111/j.1526-4610.1990.hed3007423.x

Ehde, D. M., Holm, J. E., & Metzger, D. L. (1991). The role of family structure, functioning and pain modeling in headache. Headache, 31, 35-40.

Flor H, Kerns RD, Turk DC. The role of spouse reinforcement, perceived pain, and activity levels of chronic pain patients. J Psychosom Res. 1987;31(2):251-259. doi:10.1016/0022-3999(87)90082-1

Haynes, S. N. (1981). Muscle contraction headache: A psychophysiological perspective of etiology and treatment. In S. N. Haynes & L. R. Gannon (Eds.), Psychosomatic disorders; A psychophysiological approach to etiology and treatment (pp. 231-276). New York: Praeger Press.

Holroyd, KA, & Andrasik, F. (1982). A cognitive-behavioral approach to recurrent tension and migraine headaches. In P.E. Kendall (Ed.), advances in cognitive-behavioral research and therapy, (Vol.1, pp275-320), New York: Academic Press.

Martin M. J. (1966). Tension headache, a psychiatric study. Headache, 6(2), 47–54. https://doi.org/10.1111/j.1526-4610.1966.hed0602047.x

Martin M. J. (1983). Muscle-contraction (tension) headache. Psychosomatics, 24(4), 319–324. https://doi.org/10.1016/s0033-3182(83)73211-1

Martin, P. R., Milech, D., & Nathan, P. R. (1993). Towards a functional model of chronic headaches: investigation of antecedents and consequences. Headache, 33(9), 461–470. https://doi.org/10.1111/j.1526-4610.1993.hed3309461.x

Martin, P. (1993). Psychological Management of Chronic Headaches: Treatment Manual for Practitioners. Guilford Press.

Penzien DB, Holroyd KA, Holm JE, Hursey KG. Psychometric characteristics of the Bakal Headache Assessment Questionnaire. Headache. 1985;25(1):55-58. doi:10.1111/j.1526-4610.1985.hed2501055.x

Philips HC. Thoughts provoked by pain. Behav Res Ther. 1989;27(4):469-473. doi:10.1016/0005-7967(89)90019-3

Philips HC. Avoidance behaviour and its role in sustaining chronic pain. Behav Res Ther. 1987;25(4):273-279. doi:10.1016/0005-7967(87)90005-2

Philips HC, Jahanshahi M. Chronic pain: an experimental analysis of the effects of exposure. Behav Res Ther. 1985;23(3):281-290. doi:10.1016/0005-7967(85)90006-3

Philips HC, Jahanshahi M. The components of pain behaviour report. Behav Res Ther. 1986;24(2):117-125. doi:10.1016/0005-7967(86)90082-3