Brief Behavioral Intervention for Comorbid Migraine and Depression

Migraine affects approximately 35 million US residents (Bigal & Lipton, 2009) and is
associated with excruciating headache and marked functional impairment. Epidemiological and
clinical research has shown that people with migraine suffer from psychiatric disorders at a
disproportionately higher rate than individuals without. Depression, in particular, is 3-5
times more common in migraine patients than in non-migraineurs. The comorbidity of depression
and migraine is a major health concern as it results in poorer prognosis, remission rate, and
response to treatment. In addition, an increase in the severity of migraine is associated
with a parallel rise in the severity and treatment resistance of comorbid depression.

Recent research in behavioral medicine suggests that the pain experience per se does not
necessarily lead to depression or impairment. Instead, it is the preoccupation with avoiding
aversive stimuli associated with pain (i.e., activities, places, movements) that results in
depression and disability (e.g., McCracken et al., 2005). Therefore, given that patients with
migraine and/or depression exhibit more avoidance behaviors and lower activity levels than
healthy controls (e.g., Stronks et al., 2004), an intervention aimed at optimizing
willingness and acceptance and minimizing behavioral avoidance may be beneficial at improving
both their depression and migraine and, consequently, their daily functioning.

Acceptance and Commitment Therapy (ACT) is an empirically based behavioral therapy that
incorporates acceptance and mindfulness strategies with behavioral change strategies. ACT (in
group and in individual settings) is effective in treating psychiatric disorders commonly
associated with migraine, including depression, anxiety, and stress (e.g., Hayes, 2001) as
well as chronic illnesses like pain and diabetes (Dahl et al, 2004; Gregg et al., 2006).
Importantly, ACT resulted in positive long-term outcomes even when presented in brief form.
For example, a two-day ACT workshop, in a group setting, led to improvements in depression
and distress experienced by parents of children diagnosed with autism and these gains were
retained 3 months later. Parents also exhibited a reduction in avoidance behaviors
(Blackledge & Hayes, 2006).

Inclusion Criteria:

- Age 18-75

- 4 to 12 migraines in the previous month

- Major or Minor Depression

- English-speaking

Exclusion Criteria:

- Patients with other major psychiatric disorders such as bipolor disorder,
schizophrenia, and current illicit drug use.

- Patients with major head injuries.

- Patients with serious medical illnesses.

- Patients who have started a new medication in previous 4 weeks or plan on starting a
new medication in the next 4 weeks.

- Patients expressing significant suicidal ideation.