Minimal-contact cognitive-behavioural treatment of chronic daily headache : the role of cognition in the efficacy and mechanisms of treatment

Objectives. To determine the efficacy of minimal-contact cognitive-behavioural therapy (MC-CBT) and conventional therapy-intensive cognitive-behavioural therapy (I-CBT) in the treatment of chronic daily headache (CDH) and to examine the cognitive mechanisms through which treatment might work.;Design and Methods. Study 1 (N = 37) employed a split-plot design to compare pre to post effects in three treatment groups (I-CBT, MC-CBT, and waiting list controls). This Study also used a correlational approach to investigate a hypothesised association between cognitive changes and outcome changes. Study 2 (N = 20) also employed a split plot design to compare MC-CBT with an almost identical minimal-contact treatment in which the explicit cognitive training component was replaced by an unstructured positive-coping-skills block (MC-PCS). Study 3 (N = 6) employed single-case methodology to investigate daily fluctuations in self-efficacy and how these relate to the application of cognitive and non-cognitive treatment strategies.;Results. Study 1. MC-CBT and I-CBT were significantly and equally effective in terms of positive outcome and adaptive cognitive change (chiefly, less catastrophising, and increase perceived self-efficacy). Moderate correlations were obtained between cognitive changes and outcome changes but a substantial part of the variance in outcome was not explained by the cognitive changes considered here. Study 2. MC-CBT was found to be significantly more effective, than MC-PCS, in maintaining treatment gains at 6-month follow-up. Study 3. A strong inverse association was found between daily change in perceived self-efficacy and daily ratings of headache activity. However, the learning of explicit cognitive strategies appeared not to make an immediate impact.;Conclusions. In contrast to previous negative findings with this supposedly refractive headache population, minimal-contact CBT is a cost-effective treatment option for CDH sufferers. Cognitive variables (particularly appraisal style and perceived self-efficacy) appear to be at the heart of the treatment mechanism, as assumed in CBT models, but the important question of causality remains unanswered. However, explicit cognitive training seems to be essential with regard to maintenance of treatment gains. The theoretical and clinical implications of these findings are discussed, and a revised CBT model for chronic headaches is proposed.