Select Page

Find a CBT Therapist

Search through our directory of local clinicians.


Headache is a frequent medical complaint. Only the common cold occurs more often. The Nuprin Pain Report found that almost 3 out of 4 American adults experienced some form of headache within a given year, and that the complaint of headache resulted in nearly 127 million lost workdays per year. In children, headache is a leading cause of school absences. The overwhelming majority of headache complaints is diagnosed as vascular or tension. The National Headache Foundation estimates that over 10 million Americans are troubled by recurrent migraines, a form of vascular headache. In addition, tension headache likely affects 3 to 4 times as many individuals as do migraines. Both forms of headache are more prevalent in females. They do not appear to be related to social class or occupation; they can occur in virtually anyone at anytime.

Mechanisms and Symptoms of Vascular and Tension Headaches

A migraine or “sick headache,” is experienced as a sudden onset, most often one-sided, intensely throbbing pain. Attacks are intermittent, lasting from a few hours to as long as a day or more. Nausea, vomiting, loss of appetite, fatigue, and sensitivity to sound and light frequently accompany a migraine headache. A typical reaction to this type of vascular headache is to seek a quiet, darkened area to lie down and “ride out” the pain. A brief aura (physical warning sign) occurs in about 10% to 15% of cases; these types of migraine headaches are termed “classic.” Auras are most often visual: the sufferer sees flashing lights or zigzag lines or experiences a gap in the visual field. Migraines lacking strong, clear warning symptoms are labeled “common.”

Biochemical imbalances, fluctuations in cranial blood flow, and certain neurological events are thought to underlie migraine.

Cluster headache is another type of vascular headache. It is named because of frequent headaches of short duration. These headaches then go away for extended periods. These headaches can be exceedingly painful and are often described as a stabbing pain (“like a hot poker in my eye”). Cluster headache is rare and is the only type of headache more common in males than females. Waking from sleep with a headache, blockage and/or running of the nose, and redness and tearing of the eye on the same side as the head pain are hallmarks of cluster headache.

Tension, or muscle contraction, headache is believed to result from excessive tightening of muscles in the shoulders, neck, and head. This tightening affects oxygen and nutrient intake to the muscles. It also impinges on pain-sensitive structures. Both factors contribute to the experience of pain. The typical tension headache is experienced as a dull, steady, viselike ache that waxes and wanes in intensity. It is often two-sided with gradual-onset. It is not unusual for this type of headache to be a daily occurrence.

Headaches can be a sign of a serious biological problem. It is always wise for people to have their symptoms evaluated by a medical specialist. This is especially important for a series of new headaches. Also, see a specialist when headaches have become worse or more frequent.

Causes of Vascular and Tension Headaches

Both forms of headache can be brought on or made worse by many factors. Changing hormone levels, alcohol, physical exertion, and birth control pills are just a few of the identified links to migraine headache. Diets that include caffeine, chocolate, ripened cheese, etc. have been linked to migraine headaches. Even medications routinely prescribed for headache can intensify symptoms when they wear off. This is especially possible if taken at abusively high levels. This is called “medication rebound headache.”

Doctors have long noted a link between stress and headaches. Stress can be related to headache in three ways. Stress can directly set off the biological events underlying headache. Stress can intensify an existing headache. The prolonged presence of a headache can itself begin to exert a psychological toll (or stress) on the individual. The person becomes “sick and tired of feeling sick and tired”. Depression and anxiety sometimes occur in people with headaches of long-standing, unremitting origin.

Many people with headaches feel better with rest, vacation, and over the counter drugs. For some people, these self-treatments do not work. These people are candidates for further specialized medical care. This can include newly developed drug-free treatment approaches such as behavior therapy.

Behavior Therapy Treatment Approaches

The behavior therapist first assists the patient in studying factors that might bring on, maintain, or worsen headaches. The patient may be asked to keep track of these factors each day. This is done with a “headache diary.” The patient also rates pain, frequency, severity, and duration. The information is helpful in judging progress during treatment. Three behavior therapy techniques have been developed for use with headache patients: biofeedback therapy, relaxation training, and stress coping training.


Biofeedback teaches patients how to control the bodily processes that bring about headache. For example, in the treatment of tension headache, sensors are attached to the affected muscles (on the skin surface) so that the patient is provided ongoing information, or “feedback,” about activity in the monitored muscles. Armed with this information, the patient strives to lower the muscle activity to a more acceptable level. This is a way of alleviating pain. Biofeedback therapy for migraine involves teaching patients one of two ways to control the body. One way is through control of hand surface temperature. This provides a good index of nervous-system arousal and blood flow. Another way is through monitoring blood flow in the temple area. This is a common site of migraine.

Relaxation Skills

Relaxation also teaches control of one’s body. A common relaxation method is to do a series of exercises. The exercises involve tensing and releasing muscles. This helps the patient to feel relaxed. Biofeedback works with specific bodily response systems. Relaxation works on the entire body.

Stress Coping

Stress coping training provides patients with a general set of problem solving or coping skills. These can be used to manage a wide range of situations associated with headache. This treatment uses various cognitive and behavioral treatment methods. These keep stress factors more manageable. Patients may be taught how to become less reactive emotionally. They may be taught to interpret potentially upsetting situations more objectively. They are taught to manage time, interpersonal situations, and the like. They are also taught to react better to the psychological distress that can result from chronic headache itself. Often the behavior therapist will combine all of these methods.

Many patients seen by a behavior therapist also see a medical doctor. The doctor may provide drugs and other medical treatments. The behavior therapist typically maintains close contact with the doctor. This ensures that treatment remains coordinated. Reviews of research studies reveal that all three types of treatment are similar in effectiveness. They lead to meaningful improvement in about 40% to 60% of patients. Not all patients successfully treated become completely symptom free. For some, treatment worked if the patient copes better with headache. For some, treatment worked if the presence of headache no longer disrupts planned activities.

What is Cognitive Behavior Therapy?

My Account Info

Manage your Membership information, email preferences, and more.


Membership in ABCT grants you access to three journals.


Convention Registration is now open for the 2023 ABCT Convention in Seattle, WA.