Understanding and Promoting Resiliency in Patients with Chronic Headache

  • Cynthia M. StonningtonEmail author
  • Dhwani J. Kothari
  • Mary C. Davis
Headache (R Halker, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Headache


Even among patients with the same type and severity of headache, there is considerable variability in functional outcomes. Some individuals are resilient, able to thrive despite pain, whereas others find that pain is an overwhelming burden that comes to define their lives. A substantial body of evidence suggests that patients’ cognitive, emotional, and behavioral coping responses to their pain play a significant role in determining their long-term health. Resilient pain responses, which are shaped by both qualities of the individual and his/her social environment, can be learned and thus hold promise as targets for treatment. We draw on recent empirical findings that identify which pain beliefs, appraisals, and behaviors in response to pain are key to resilient and non-resilient coping among patients with chronic headache. We discuss how pain self-efficacy and pain acceptance set the stage for adaptive behaviors that have been linked to sustained well-being and good quality of life. We then describe psychosocial and behavioral interventions that show promise in promoting resilience among headache patients and conclude by considering areas ripe for further inquiry.


Headache Resilience Functional health Acceptance Self-efficacy Values-based action 



The authors thank Betty Darby, Ph.D., for her helpful comments and for the development of the Mindfulness-Based Resilience Training programs for patients and employees at Mayo Clinic, which informed and inspired some of the content of this article.


No funding was applied to this review paper.

Compliance with Ethical Standards

Conflict of Interest

Cynthia M. Stonnington, Dhwani J. Kothari, and Mary C. Davis declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007;27:193–210.PubMedCrossRefGoogle Scholar
  2. 2.
    Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Pychol. 2002;70:678–90.CrossRefGoogle Scholar
  3. 3.
    Marks R, Allegrante JP, Lorig K. A review and synthesis of research evidence for self-efficacy-enhancing interventions for reducing chronic disability: implications for health education practice (Part I). Health Promot Pract. 2005;6:37–43.Google Scholar
  4. 4.
    Sullivan MJL, Thorn BE, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, et al. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Stroud MW, Thorn BE, Jensen MP, Boothby JL. The relation between pain beliefs, negative thoughts, and psychosocial functioning in chronic pain patients. Pain. 2000;84:347–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Arnstein P. The mediation of disability by self efficacy in different samples of chronic pain patients. Disabil Rehabil. 2000;22:794–801.PubMedCrossRefGoogle Scholar
  7. 7.
    Arnstein P, Caudill M, Mandle CL, Norris A, Beasley R. Self efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain. 1999;80:483–91.PubMedCrossRefGoogle Scholar
  8. 8.
    Turner JA, Ersek M, Kemp C. Self-efficacy for managing pain is associated with disability, depression, and pain coping among retirement community residents with chronic pain. J Pain. 2005;6:471–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Kalapurakkel S, Carpino EA, Lebel A, Simons LE. “Pain can’t stop me”: examining pain self-efficacy and acceptance as resilience processes among youth with chronic headache. J Pediatr Psychol. 2014;jsu091:1–9.Google Scholar
  10. 10.•
    Carpino E, Segal S, Logan D, Lebel A, Simons LE. The interplay of pain-related self-efficacy and fear on functional outcomes among youth with headache. J Pain. 2014;15:527–34. In this cross-sectional study of 199 youth with headache, self-efficacy was strongly associated with fear, disability, school impairment, and depressive symptoms. Confidence in the ability to function despite pain and fear- avoidance each independently influenced pain-related outcomes. These results suggest that treatment for chronic headache in youth should focus on both decreasing pain-related fear and increasing pain-related self-efficacy.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Jensen MP, Turner JA, Romano JM, Karoly P. Coping with chronic pain: a critical review of the literature. Pain. 1991;47:249–83.PubMedCrossRefGoogle Scholar
  12. 12.••
    Gillanders DT, Ferreira NB, Bose S, Esrich T. The relationship between acceptance, catastrophizing and illness representations in chronic pain. Eur J Pain. 2013;17:893–902. This study examined how the processes of acceptance, catastrophizing, and illness representations relate to emotional and physical functioning in 150 chronic pain patients. Catastrophizing and emotional representations were found to influence emotional dysfunction, while acceptance had more influence on physical disability. Pain severity itself was a relatively poor predictor of emotional and physical dysfunction.PubMedCrossRefGoogle Scholar
  13. 13.
    Holroyd KA, Drew JB, Cottrell CK, Romanek KM, Heh V. Impaired functioning and quality of life in severe migraine: the role of catastrophizing and associated symptoms. Cephalalgia. 2007;27:1156–65.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour. A prospective study. Pain. 2001;94:85–100.PubMedCrossRefGoogle Scholar
  15. 15.
    McKnight PE, Afram A, Kashdan TB, Kasle S, Zautra A. Coping self-efficacy as a mediator between catastrophizing and physical functioning: treatment target selection in an osteoarthritis sample. J Behav Med. 2010;33:239–49.PubMedCrossRefGoogle Scholar
  16. 16.
    Keefe FJ, Kashikar-Zuck S, Opiteck J, Hage E, Dalrymple L, Blumenthal JA. Pain in arthritis and musculoskeletal disorders: the role of coping skills training and exercise interventions. J Orthop Sports Phys Ther. 1996;24:279–90.PubMedCrossRefGoogle Scholar
  17. 17.
    Davis MC, Zautra AJ, Smith BW. Chronic pain, stress, and the dynamics of affective differentiation. J Pers. 2004;72:1133–60.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 18.
    Martin PR. Managing headache triggers: think ‘coping’ not ‘avoidance’. Cephalalgia. 2010;30:634–7.PubMedGoogle Scholar
  19. 19.
    Martin PR. How do trigger factors acquire the capacity to precipitate headaches? Behav Res Ther. 2001;39:545–54.PubMedCrossRefGoogle Scholar
  20. 20.
    Martin PR, Lae L, Reece J. Stress as a trigger for headaches: relationship between exposure and sensitivity. Anxiety Stress Coping. 2007;20:393–407.PubMedCrossRefGoogle Scholar
  21. 21.
    Martin PR, Reece J, Forsyth M. Noise as a trigger for headaches: relationship between exposure and sensitivity. Headache. 2006;46:962–72.PubMedCrossRefGoogle Scholar
  22. 22.
    McCracken LM, Zhou-O’Brien J. General psychological acceptance and chronic pain: there is more to accept than the pain itself. Eur J Pain. 2010;14:170–5.PubMedCrossRefGoogle Scholar
  23. 23.••
    Foote HW, Hamer JD, Roland MM, Landy SR, Smitherman TA. Psychological flexibility in migraine: a study of pain acceptance and values-based action. Cephalagia. 2015. Using validated measures of psychological flexibility and headache-related disability, this study of 103 migraine sufferers found that acceptance of pain and values-based action were strongly associated with headache frequency and disability and had a greater influence on disability than headache severity or frequencyGoogle Scholar
  24. 24.
    Chiros C, O’Brien WH. Acceptance, appraisals, and coping in relation to migraine headache: an evaluation of interrelationships using daily diary methods. J Behav Med. 2011;34:307–20.PubMedCrossRefGoogle Scholar
  25. 25.
    Day MA, Thorn BE, Rubin NJ. Mindfulness-based cognitive therapy for the treatment of headache pain: a mixed-methods analysis comparing treatment responders and treatment non-responders. Complement Ther Med. 2014;22:278–85.PubMedCrossRefGoogle Scholar
  26. 26.
    Jensen MP, Vowles KE, Johnson LE, Gertz KJ. Living well with pain: development and preliminary evaluation of the valued living scale. Pain Med. 2015. doi: 10.1111/pme.12802.Google Scholar
  27. 27.
    Fredrickson BL. The role of positive emotions in positive psychology. Am Psychol. 2001;56:218–26.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Kent M, Davis MC. Resilience training for action and agency to stress and trauma: becoming the hero of your life. In: Kent M, Davis MC, Reich JV, editors. The resilience handbook: approaches to stress and trauma. New York: Routledge Press; 2014. p. 227–44.Google Scholar
  29. 29.
    Hayes SC, Levin ME, Plumb-Vilardaga J, Villatte JL, Pistorello J. Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44:180–98.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Ozbay F, Fitterling H, Charney D, Southwick S. Social support and resilience to stress across the life span. Curr Psychiatry Rep. 2008;10:304–10.PubMedCrossRefGoogle Scholar
  31. 31.
    McCluskey S, de Vries H, Reneman M, Brooks J, Brouwer S. ‘I think positivity breeds positivity’: a qualitative exploration of the role of family members in supporting those with chronic musculoskeletal pain to stay at work. BMC Fam Pract. 2015;16:1–7.CrossRefGoogle Scholar
  32. 32.
    Lewandowski AS, Palermo TM, Stinson J, Handley S, Chambers CT. Systematic review of family functioning in families of children and adolescents with chronic pain. J Pain. 2010;11:1027–38.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Stensland SØ, Thoresen S, Wentzel-Larsen T, Zwart JA, Dyb G. Recurrent headache and interpersonal violence in adolescence: the roles of psychological distress, loneliness and family cohesion: the HUNT study. J Headache Pain. 2014;15:1–9.CrossRefGoogle Scholar
  34. 34.
    Zautra AJ, Infurna FJ, Zautra E, Gallardo C, Velasco L. The humanization of social relations: nourishment for resilience in mid-life. In: Ong A, Corinna E, Löckenhoff CE, editors. New developments in emotional aging. Washington: American Psychological Association; 2015.Google Scholar
  35. 35.
    Gittleman M. Behavioral approaches to headache: a practical guide for non-mental health providers. Tech Reg Anesth Pain Manag. 2012;16:69–75.CrossRefGoogle Scholar
  36. 36.
    Lipchik GL, Nash JM. Cognitive-behavioral issues in the treatment and management of chronic daily headache. Curr Pain Headache Rep. 2002;6:473–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Kropp P, Meyer B, Landgraf M, Ruscheweyh R, Ebinger F, Straube A. Headache in children: update on biobehavioral treatments. Neuropediatrics. 2013;44:20–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Starling AJ, Dodick DW. Best practices for patients with chronic migraine: burden, diagnosis, and management in primary care. Mayo Clin Proc. 2015;90:408–14.PubMedCrossRefGoogle Scholar
  39. 39.
    Nicholson RA. Chronic headache: the role of the psychologist. Curr Pain Headache Rep. 2010;14:47–54.PubMedPubMedCentralCrossRefGoogle Scholar
  40. 40.
    Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurol. 2000;55:754–62.CrossRefGoogle Scholar
  41. 41.
    Morley S, Williams A, Hussain S. Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: evaluation of a CBT informed pain management programme. Pain. 2008;137:670–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Eccleston C, Palermo TM, Williams AC, Lewandowski HA, Morley S, Fisher E, et al. Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev. 2014;5:CD003968. doi: 10.1002/14651858.
  43. 43.
    Krishnan A, Silver N. Headache (chronic tension-type). BMJ Clin Evid. 2009;7:1205.Google Scholar
  44. 44.
    Kjeldgaard D, Forchhammer H, Teasdale T, Jensen RH. Chronic post-traumatic headache after mild head injury: a descriptive study. Cephalagia. 2014;34:191–200.CrossRefGoogle Scholar
  45. 45.
    Rains JC, Penzien DB, McCrory DC, Gray RN. Behavioral headache treatment: history, review of the empirical literature, and methodological critique. Headache. 2005;45:S92–109.PubMedCrossRefGoogle Scholar
  46. 46.
    Kabat-Zinn J, Hanh T. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York: Random House Publishing Group; 2009.Google Scholar
  47. 47.
    Rosenzweig S, Greeson JM, Reibel DK, Green JS, Jasser SA, Beasley D. Mindfulness-based stress reduction for chronic pain conditions: variation in treatment outcomes and role of home meditation practice. J Psychosom Res. 2010;68:29–36.PubMedCrossRefGoogle Scholar
  48. 48.
    Omidi A, Zargar F. Effect of mindfulness-based stress reduction on pain severity and mindful awareness in patients with tension headache: a randomized controlled clinical trial. Nurs Midwifery Study. 2014;3:e21136.CrossRefGoogle Scholar
  49. 49.
    McGuire V, Egan J, Traynor A. Online mindfulness-based stress reduction for the management of chronic headache pain in adults. Pain Res Manag. 2014: 35th Annual Scientific Meeting of the Canadian Pain Society Quebec City, QC Canada. Conference Publication: (var.pagings). 2014;19(3):e60.Google Scholar
  50. 50.
    Mo’tamedi H, Rezaiemaram P, Tavallaie A. The effectiveness of a group-based acceptance and commitment additive therapy on rehabilitation of female outpatients with chronic headache: preliminary findings reducing 3 dimensions of headache impact. Headache. 2012;52:1106–19.PubMedCrossRefGoogle Scholar
  51. 51.
    Dindo L, Recober A, Marchman J, O’Hara MW, Turvey C. One-day behavioral intervention in depressed migraine patients: effects on headache. Headache. 2014;54:528–38.PubMedPubMedCentralCrossRefGoogle Scholar
  52. 52.•
    Penzien DB, Irby MB, Smitherman TA, Rains JC, Houle TT. Well-established and empirically supported behavioral treatments for migraine. Curr Pain Headache Rep. 2015;19:34. The authors provide an overview of well-established and empirically supported behavioral interventions for the treatment of migraine. Review of the evidence suggests that interventions such as relaxation, biofeedback, and stress management training are as effective as pharmacological therapies for migraine. However, the availability and implementation of behavioral approaches remain limited for many headache sufferers. Advances in technology promise to enable migraine patients’ greater access for such behavioral treatments.PubMedCrossRefGoogle Scholar
  53. 53.
    Pickering G, Creac’h C, Radat F, Cardot JM, Alibeu JP, Andre G, et al. Autogenic training in patients treated for chronic headache: a randomised clinical trial. J Pain Manag. 2012;5:195–205.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Cynthia M. Stonnington
    • 1
    Email author
  • Dhwani J. Kothari
    • 2
  • Mary C. Davis
    • 2
  1. 1.Department of Psychiatry and PsychologyMayo Clinic in ArizonaScottsdaleUSA
  2. 2.Department of PsychologyArizona State UniversityTempeUSA

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