Methods
We retrospectively analyzed data from 98 consecutive patients presenting to the headache clinic of Hadassah University Hospital and meeting the International Classification of Headache Disorders-II diagnostic criteria for frequent episodic TTH (FETTH), chronic TTH (CTTH), or medication-overuse headache (MOH).
All patients were managed according to our standard protocol that includes several steps: (1) thorough explanation regarding the nature of their condition and the role of medications in exacerbating the pain (where relevant); (2) reassurance of the benign nature of their condition; (3) explanation suggesting 2 possible treatment options – HR or AMT therapy. Advantages and disadvantages of each management option (including aspects of time commitment and adverse effects) were described without any preference being expressed by the interviewing neurologist (Y. E.). The patients were allowed to switch therapies following initiation of either treatment protocol.
Patients selecting AMT received 10 mg each evening before bed and then increased the doses after 3 weeks to 25 mg and then by 25 mg every 3 weeks up to a dose of 75 mg according to response and adverse effects. Patients who opted for HR were offered 3 sessions of relaxation training to learn self-HR and guided imagination. These were undertaken during standard-length neurology-clinic appointments (up to 30 minutes). The first session included teaching progressive relaxation of 10 groups of muscles and then focusing on breathing. All the sessions were done with hypnotic techniques, namely monotonic speech, repetition, positive suggestion, pacing, and leading. After noticing that the patient began to enter the trance, suggestions were added to encourage relaxation of the head muscles and a feeling of well-being. At the end of the session it was suggested that they will be able to reproduce this feeling easily any time they repeat this exercise.
The second session reviewed the relaxation technique and included recording the exercises; during the third session the patient was taught how to induce a trance quickly and how to apply the technique to everyday life. Between the meetings the patient was told to practice relaxation 3 times a day 5–10 minutes at home. Patients were asked whether they had adhered to the practice schedule.
Both groups of patients were offered the same follow-up conditions. Headache assessment was performed at initial consultation by completion of a questionnaire that was composed by us. The questionnaire included questions on headache characteristics that were evaluated according to the mean pain rating scale, frequency, duration, and analgesic use. This assessment was repeated via follow-up phone interviews 6 to 12 months later by a trained nurse from the headache clinic, and included a question on global self-health appraisal.
Statistical analysis was performed using the SPSS statistical package (SPSS, Chicago, IL, USA). Univariate analysis was performed with each of the dependent variables, by cross-tabulation and the χ test for categorical variables, and one-way analysis of variance for continuous variables.
The study was approved by our institutional ethics committee.