Editorial

When Less Becomes More

John Edmeads

In this issue of Headache are two studies of cognitive-behavioural treatment which are interpreted by theirauthors as demonstrating that it is possible to achieve, through the low-cost modalities of group therapy orself-treatment, reductions in headache equivalent to those resulting from the conventional and moreexpensive one therapist-one patient format. If their conclusions are correct, the implications of thiscost-benefit assessment are significant.

Richardson and McGrath1 treated 48 common migraine patients in three "conditions" - a wait list controlgroup, a clinic-based regimen, and a home study regimen. In the clinic-based condition, individual patientsmet with their therapist one hour per week for 8 weeks; they were educated about the emotions-headacherelationship, were taught several cognitive skills, and were trained (with the aid of audiotapes) in relaxation,with home practice. In the minimal-therapist-contact condition, patients met the therapist twice, each time forhalf an hour; the information and training were given at home by a self-help manual and audiotapes, with thepatient completing homework assignments and sending them with a headache diary to the therapist.

At the 6 month follow-up, both treatment groups showed "statistically significant improvement",intra-groups and in comparison to the controls - but there were no significant differences in outcome betweenthe two treatment groups. Using a more clinically relevant (but also more stringent) index, the number ofsubjects in the 3 groups who obtained at least a 50% reduction in headache activity, it turned out that thisoccurred in 18% of the controls, 33% of the minimal-therapist-contact group, and 47% of the clinic-basedgroup. These success rates are not dramatic but the point is that such success that there was could beobtained 31/2 times more cheaply using the minimalist technique.

Johnson and Thorn2 assigned 22 chronic headache (type unspecified) patients to either a wait list controlcondition, a conventional individual therapy condition, or a group therapy condition. The individual and grouptherapy patients attended 5 weekly one hour sessions in which their headache records were reviewed, theywere instructed in the nature of chronic headaches and/or coping strategies, and they were trained inrelaxation techniques with instructions to practice at home.

At the 6 month follow-up, there was statistically significant "within group" improvement for many patients inall three of the conditions, but no evidence that either of the treatment groups fared better than the wait listcontrol group. The authors made the best of the situation by stating "...the results . . . suggest that short-termcognitive-behavioural treatment is effective in . . . chronic headache, based on changes seen within treatmentgroups pre-versus-posttreatment. Since no differences were found in the relative efficacy of group andindividual treatment formats, a case can be tentatively made that group cognitive-behavioural treatment forchronic headache is the format of choice on the basis of time and cost effectiveness". (Doubtless there willbe some who will argue that, given the results, the most time-and-cost-effective method would be to wait-listthe patient.)

Efficacy aside, the point of these papers is that psychologists are now assessing their therapies in terms ofrelative resource expenditures and cost-benefit ratios . . . catchwords that bring a sparkle to the eyes of thirdparty payers. It is only a matter of time until the third party payers demand from us headache doctors a similaranalysis of our own treatment practices. Will we be ready?

REFERENCES

1. Richardson GM, McGrath PJ: Cognitive-behavioural therapy for migraine headaches: aminimal-therapist-contact approach versus a clinic-based approach. Headache 29:352-357, 1989.

2. Johnson PR, Thorn BE: Cognitive behavioural treatment of chronic headache: group versus individualtreatment format. Headache 29:000-000, 1989.