The high dropout rate 38 of patients from biofeedback

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combined treatment. The high dropout rate (38% of patients) from biofeedback training alone raises the possibility that outcomes were compromised by poor patient compliance. Clinical trials are needed to provide information about the distinct benefits of psychological and preventive drug therapies for moderate and high-severity migraine. For example, for frequent disabling—high severity—migraines, a trial might ask whether preventive drug therapy, psychological treatment, or combined therapy best adds to benefits achieved with migraine-specific (triptan) medication. For less frequent and disabling—moderate severity—migraine, a trial might ask whether migraine-specific medication or brief home-based psychological treatment is more cost-effective in the long-term management of migraines. Tension-Type Headache Two new studies provide information about the benefits of combined psychological and drug therapy for tension-type head- ache. Reich & Gottesman (1993) examined the benefits of adding amitriptyline (up to 75 mg/day) to an intensive (30-session) multiple-site EMG-BF protocol. The combination of amitriptyline HCl and EMG-BF yielded more rapid improvement in tension- type headache activity than EMG-BF alone; however, beginning at Month 8 and continuing through the 24-month evaluation period, the combined treatment showed no advantage over EMG-BF alone. In fact at the 20- and 24-month observation periods—after withdrawal from amitriptyline HCl—patients who had received EMG-BF alone recorded significantly fewer hours of headache activity than patients who had received the combined treatment. Holroyd and colleagues ( N 203; Holroyd et al., 2001) exam- ined the separate and combined effects of CBT and tricyclic antidepressant medication for CTTHs. Patients received one of four treatments: tricyclic antidepressant medication (amitriptyline HCl to 100 mg/day or nortriptyline HCl to 75 mg/day), medication placebo, limited-contact CBT (three clinic sessions) plus antide- pressant medication, or CBT plus placebo. Antidepressant medi- cation and CBT yielded similar reductions in CTTHs, analgesic medication use, and headache-related disability at a 6-month eval- uation, but improvements tended to be more rapid in the two- antidepressant-medication conditions than with CBT alone (see Figure 3). However, the combined treatment was more likely (64% of patients) to produce clinically significant ( 50%) reductions in CTTHs than either antidepressant medication alone (38% of pa- tients) or CBT medication (35% of patients). The combination of antidepressant medication and CBT ap- pears to be a promising treatment for chronic tension-type head- ache, particularly for patients who do not respond to one of the individual treatments. Nonetheless, methods of enhancing the ef- fectiveness of this treatment are needed, because many patients continue to experience frequent headaches even following the combined treatment. Information about the long-term treatment outcomes with CTTH are also needed, because CTTH may be more prone to relapse than ETTH, particularly following withdrawal of antidepressant medication. The possibility that CBT or other psy-
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